Zambia HIV/AIDS Prevention, Care and Treatment (ZPCT) Partnership Cooperative Agreement No. 690-A-00-04-00319-00 Quarterly Report for July 1 – September 30, 2008 Submitted by Family Health International (FHI) October 31, 2008

1. EXECUTIVE SUMMARY

The HIV/AIDS Prevention, Care and Treatment Partnership (ZPCT) works with the Ministry of Health (MOH), the Provincial Health Offices (PHOs), and District Health Management Teams (DHMTs) to strengthen and expand HIV/AIDS related services in five provinces: Central, Copperbelt, Luapula, Northern and North Western. ZPCT supports the Government of the Republic of Zambia (GRZ) goals of reducing prevalence rates and providing antiretroviral therapy (ART) by implementing technical, program and management strategies to initiate, improve and scale-up prevention of mother-to-child transmission (PMTCT), counseling and testing (CT) and clinical care services for people living with HIV/AIDS (PLHA), including ART.

This quarter, ZPCT supported implementation of HIV/AIDS services in 220 health facilities in 35 districts in the five target provinces, with 219 of these facilities now reporting results. The health facility in in has started services but is not yet reporting.

. Key activities and achievements for this reporting period include: CT services are ongoing in 218 out of 219 reporting health facilities, with 40,859 individuals receiving CT services in these facilities. PMTCT services were provided in 209 ZPCT supported facilities. 34,783 women were provided with PMTCT services (including CT), and 4254 were provided with a complete course of ARV prophylaxis. Ongoing technical assistance was provided to expand and improve clinical palliative care services in all targeted health facilities. 83,708 individuals received palliative care in all 219 reporting ZPCT supported health facilities during this quarter. ART services were available in 34 districts supported by ZPCT. It is still to be determined if the site in Milenge District will have the capacity to provide ART services in the future. This quarter a total of 6137 new clients (including 447 children) were initiated on antiretroviral therapy through 96 (including 50 outreach sites) out of the total 101 planned ART centers. Of the 96 ART sites, 90 report independently and 6 sites report through the bigger facilities. By the end of this reporting period 62,128 individuals were receiving antiretroviral therapy at ZPCT-supported sites and of these, 4227 were children. The following training courses were conducted this quarter: 61 HCWs and 57 community volunteers were trained in basic CT through three, two-week courses. 28 HCWs already trained in basic CT, were trained in child counseling. 30 community volunteers already trained in basic CT were trained in child counseling through two, one- week courses. 20 HCWs were trained in counseling supervision through a two-week course. 43 HCWs were trained in three, two-week courses in provision of PMTCT services. 20 community volunteers were trained in provision of PMTCT services through a one-week course. 101 HCWs were trained in pediatric ART and opportunistic infection (OI) management through three, one-week courses. 47 pharmacy and 16 laboratory staff were trained in commodity management. 174 HCWs were trained in dry blood spot (DBS) collection, storage and transport. 36 M&E staff and data entry clerks were trained in SmartCare software use.

In addition, 46 already trained practicing PMTCT HCWs were retrained and updated in a PMTCT refresher course. QA/QI tools have been adapted for use in ZPCT-supported sites and are administered on a quarterly basis to assess, monitor and improve the quality of HIV services. The tools are used to assess the extent to which services are consistent with public health policy and guidelines for the treatment and prevention of HIV disease and related opportunistic infections. Data from implementation of the tools are being entered and analyzed using the CSPro software package. The districts across the five provinces that were identified for graduation by September 30, 2008 have not been graduated. ZPCT and MOH have been working together to monitor QA/QI tools and offer guidance to facility staff on how best they can improve and provide services of good quality. However, graduation plans have continued for seven districts to be graduated by December 31 2008. District-wide referral networks are fully functional in 20 districts and are in development in 14 additional districts. Initiation of referral network activities is planned in all ZPCT-supported districts during this workplan period. ZPCT has identified and worked with 18 community groups to implement community purchase orders to enable the groups to conduct mobilization activities in communities surrounding ZPCT-supported facilities. Community mobilization activities are underway in all five ZPCT-supported provinces. ZPCT staff members continue to provide assistance and leadership on technical and programmatic issues in all key areas at the central level. ZPCT actively participates on eight national technical working groups, as well as several ad-hoc implementation groups.

Results for the quarter are summarized in the following table:

Services in Health Facilities Receiving ZPCT Support Achievements (May 1, 2005 to September 30, 2008) Workplan Cumulative Indicator Quarterly Achievements Achieve (1 Oct 07 to LOP (1 Jul 08 to 30 Sep 08) ments 30 Sep 08) Percent Achievement (1 Oct Achievement s 07 to 30 (1 May 05 to TARGET FEMALE MALE TOTAL Sep 08) 30 Sep 08) CT Service outlets providing CT 216 218 Persons trained in CT 680 198 614 90% 1,606 Persons receive CT 54,000 21,039 19,820 40,859 152,688 283% 315,121 services PMTCT Service outlets providing 199 209 PMTCT Persons trained in PMTCT 400 111 480 120% 920 Pregnant women provided with PMTCT services, 84,000 34,783 34,783 119,004 142% 236,566 including CT Pregnant women provided with a complete course of 15,750 4,254 4,254 12,630 80% 23,310 ART prophylaxis Basic Health Care and Support Service outlets providing clinical palliative care 216 219 services Service outlets providing general HIV-related 216 219 palliative care Persons provided with OI management and/or 66,690 48,736 34,972 83,708 87,771 132% 92,457 prophylaxis

ZPCT Quarterly Report (July 1 – September 30, 2008) 2 Services in Health Facilities Receiving ZPCT Support Achievements (May 1, 2005 to September 30, 2008) Workplan Indicator Quarterly Achievements (1 Oct 07 to (1 Jul 08 to 30 Sep 08) 30 Sep 08) Persons provided with general HIV-related 66,690 48,736 34,972 83,708 87,771 132% 92,457 palliative care Persons trained to provide 200 222 528 264% 1,555 general HIV- related care Treatment Service outlets providing 96 90 ART services Health workers trained in 200 222 528 264% 1,555 ART New clients receiving ART 15,600 3,618 2,519 6,137 23,453 150% 63,072 Total clients receiving ART 51,300 37,190 24,938 62,128 62,128 121% 62,128 Pediatric Treatment Health workers trained in 150 101 187 125% 551 pediatric care New pediatric clients 1,560 185 262 447 1,688 108% 4,439 receiving ART Total pediatric clients 5,130 2,082 2,145 4,227 4,227 82% 4,227 receiving ART TB and Care TB infected clients receiving 7,000 665 779 1,444 5,190 74% 11,400 CT services HIV-infected clients attending HIV care/treatment services that 4,300 491 560 1,051 4,261 99% 7,776 are receiving treatment for TB disease (new cases)

Laboratory Infrastructure

Number of laboratories with capacity to perform 1) HIV 41 81 tests and 2) CD4 tests and/or lymphocyte tests Number of individuals trained in the provision of 60 200 333% 318 lab-related activities Number of tests performed at USG-supported laboratories during the reporting period: 1) HIV 372,254 184,217 671,197 180% 1,249,311 testing, 2) TB diagnostics, 3) syphilis testing, and 4) HIV disease monitoring

ZPCT Quarterly Report (July 1 – September 30, 2008) 3 2. INTRODUCTION

The Zambia Prevention, Care and Treatment Partnership (ZPCT) works with the Ministry of Health (MOH), the Provincial Health Offices (PHOs), and District Health Management Teams (DHMTs) to strengthen and expand HIV/AIDS related services in five provinces: Central, Copperbelt, Luapula, Northern and North Western. ZPCT supports the Government of the Republic of Zambia (GRZ) goals of reducing prevalence rates and providing antiretroviral treatment (ART), by implementing program and management strategies to initiate, improve and scale up prevention of mother-to-child transmission (PMTCT), counseling and testing (CT) and clinical care services for people living with HIV/AIDS (PLHA), including ART programs in all ZPCT-supported districts in these five provinces. ZPCT collaborates with the PHOs and DHMTs to strengthen service delivery at public sector facilities and to strengthen networks for referral between these and other public sector health services and communities. ZPCT also collaborates actively with other donor agencies and partner organizations to build on, rather than duplicate, HIV/AIDS programming.

ZPCT provides support at national, provincial, district and community levels utilizing health clinics, hospitals and community service delivery programs. At the national level, the program offers technical assistance and coordination to the MOH and the National AIDS Council (NAC), as requested. At the provincial level, the program supports the MOH through technical assistance and coordination in five provinces, and at the district level ZPCT assists the DHMTs and selected health facilities to provide, improve, and expand HIV/AIDS services. At the community level activities include demand creation for services and strengthening linkages between facilities and communities.

ZPCT is flexible enough to respond to requests from the MOH as needs arise. Furthermore, all activities and related monitoring and evaluation processes and indicators are designed to meet USAID and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) requirements, and to be compatible with established government health management information systems (HMIS).

3. OBJECTIVES

The specific objectives of the ZPCT Partnership are to: Increase access to and use of HIV counseling and testing (CT) Increase access to and use of interventions for preventing mother-to-child transmission (PMTCT) Increase access to and strengthen delivery of clinical care for HIV/AIDS, including diagnosis, prevention and management of opportunistic infections (OIs), and other HIV related conditions and symptoms Increase access to and strengthen delivery of ART services at the provincial and district levels

These objectives will be met within the framework of the GRZ plan for scale up of ART programs and in full partnership with the MOH at all levels.

4. ACTIVITIES AND ACCOMPLISHMENTS FOR THE QUARTER

4.1. Program Management

4.1.1. ZPCT Partners

Management Sciences for Health (MSH), the partner responsible for laboratory and pharmaceutical assistance, continues to provide technical leadership within ZPCT and nationally in these areas. Churches Health Association of Zambia (CHAZ) continues to support seven mission health facilities: St. Kalemba Health Center in , Luwi Health Center in and Chitokoloki Mission Hospital in (North Western Province), Chilubula Mission Health Center in (Northern Province), Mambilima Mission Health Center in Mwense District, Lubwe Mission Hospital in and St. Paul’s Mission Hospital in (Luapula Province). The CHAZ program officer conducted monitoring and support visits to five of the seven ZPCT- supported CHAZ facilities, including; St. Kalemba, Chitokoloki Mission, Chilubula Mission, Mambilima Mission, and Lubwe Mission to monitor implementation progress on planned activities.

CHAZ continues to implement the ZPCT activities and an amendment to the existing recipient agreement was done through March 31, 2009 to continue the existing support. However, CHAZ is also ZPCT Quarterly Report (July 1 – September 30, 2008) 4 a principle recipient for HIV services through the Global Fund to fight AIDS, TB and Malaria and are also rolling out their ART program. ZPCT and CHAZ continue to discuss and resolve overlapping implementation issues. Kara Counseling and Training Trust (KCTT) is responsible for training CT counselors and counselor supervisors at ZPCT supported health facilities at the district level. A new contract with KCTT was signed for the period of October 1, 2008 to March 31, 2009 to conduct a total of seven trainings; four in basic CT for lay counselors in Central, Copperbelt, Luapula and Northern provinces and three counseling supervision trainings for HCWs in Central, Copperbelt, and Luapula provinces

4.1.2. Facility Support

Recipient Agreements At the end of this quarter, ZPCT was working with MOH staff to improve HIV/AIDS services in 220 facilities in 35 districts through 51 recipient agreements.

ZPCT executed 35 amendments to add additional equipment and renovations identified as a priority to the existing recipient agreements and extended the end date of these agreements through March 31, 2009. In addition, nine recipient agreements, ending on December 31, 2008, will also be amended through March 31, 2009. Implementation activities for Milenge District Health Office in Luapula Province to support HIV/AIDS services at Mulumbi Health Center commenced this quarter. Renovations and Environmental Site Assessments ZPCT is supporting renovations at 180 health facilities. Renovations at 85 health facilities have been completed. Currently, 95 health facilities have ongoing renovations. Bills of quantities and tender documents have been developed for all health facilities, excluding those that are in discussion with the DHMTs regarding question on completion of renovation by March 2009.

During this quarter, renovation contracts were signed for 20 health facilities and renovations completed in 15 health facilities. ZPCT provincial office staff continue to work closely with the DHMTs and facility management in the vendor selection process as well as ongoing monitoring of refurbishments. As renovations are completed, certification of quality and completeness of works is an ongoing follow-up activity by the infrastructure support officers and ZPCT’s consulting architect in collaboration with the relevant Provincial Public Works and Supply Department. ZPCT has continued to carry out environmental site assessments (ESAs) in facilities undergoing renovations funded by ZPCT, as per USAID guidelines. 141 ESAs have been completed to date of which, seven were completed this quarter. Rural Refurbishment In addition to renovations at health facilities, ZPCT identified staff housing to be renovated in order to increase the quality of working and living conditions of health care workers. This activity will contribute to addressing the human resources crisis in Zambia by enhancing staff retention in the most remote, rural areas of Northern and North Western provinces. During this quarter, renovations for the selected 52 housing structures in 22 facilities were advertised at both the district and provincial levels. ZPCT, in collaboration with the relevant PHOs, is selecting contractors to carry out the works. Contracts were developed and works commenced in eight facilities in Northern Province and six in Northwestern Province. This totals to 34 housing structures with is currently being worked on. Procurement During this quarter, procurement was initiated for newly identified equipment under recently executed recipient agreements and amendments. This quarter 65 fire extinguishers, four haemocues, three delivery kits, four delivery beds, eight diagnostic sets, 23 refrigerator thermometers and four motorbikes were procured and delivered. This equipment was received from vendors and delivered to respective facilities.

The ten vehicles that were procured for the ZPCT provincial offices have been received and will be distributed to the provincial offices after all the clearing procedures are completed.

Graduation Graduation plans are a continual process as we address the many challenges faced in implementing this strategy. ZPCT provincial offices continue to plan with their respective provincial health directors

ZPCT Quarterly Report (July 1 – September 30, 2008) 5 and facility in-charges to graduate the first seven districts planned for the next quarter. Additional districts will be graduated when facilities meet the requirements outlined in the QA/QI section.

4.1.3. Strategies to Supplement Human Resources at ZPCT-supported Facilities

Limited staff at health centers continues to be an issue. ZPCT approaches described below are an attempt to mitigate the human resource constraints. Health Care Workers in Facilities: ZPCT provincial offices continue to work with DHMTs and facilities to implement a transport cost reimbursement plan, which follows the districts policies. HCWs who work approved extra shifts are eligible for this reimbursement. This initiative has been implemented at most health facilities and has helped to alleviate staff shortages. ZPCT provincial staff continue to monitor this initiative closely to determine its effectiveness and feasibility and ensure that health facility staff adhere to the policy and procedures. Lay Counselors and Adherence Support Workers (ASWs): ZPCT continues to train and place lay counselors and ASWs in facilities to relieve some of the burden on HCWs in the facilities, and to improve services and the well-being of PLHA. Data Entry Clerks (DECs): All DECs are currently hired as FHI employees placed at MOH health facilities through funding included in the recipient agreements. To date, 91 DECs trained and placed by ZPCT in collaboration with the DHMTs at the ART facilities has resulted in improved timeliness and quality of HIV/AIDS data at these sites. To further improve data quality, these DECs will assist in the compilation of data from non-ART sites supported by ZPCT once a month. Outreach: Transport allowances for ART outreach have been included in all recipient agreements. This includes support for staff from the DHMT or other facilities to provide services at selected health facilities that lack a medical doctor, laboratory staff and/or pharmacy staff to initiate and monitor clients on ART.

4.1.4. Other Program Management Activities

This quarter, the following additional program management activities took place:

USAID Rules and Regulations Workshop July 28-30: Eight program officers from ZPCT Lusaka and the five provincial offices attended the three day workshop which was facilitated by staff from an organization called Inside NGO. The purpose of the workshop was to provide, share and discuss information concerning USAID policies. Notable topics that were discussed included property and procurement standards, project reports and records and sub-recipient monitoring. Participants had the opportunity to share experiences from their respective countries and discuss related issues in small groups. Certificates were also awarded to all participants. USAID Regulations Meeting (August 18-22): Eight ZPCT staff participated in a five day training on USAID administrative compliance requirements and financial management awards. The meeting was organized and offered by the Center for Public Management. The main topics that were presented and discussed included overview of major compliance requirements, source origin- nationality requirements, direct and indirect costs and cost accounting standards. Other relevant topics concerning compliance and financial management were also discussed. Supervisory Meetings: Over 30 staff occupying supervisory roles across all functional areas attended a comprehensive two day training to enhance their supervisory skills. The trainings were conducted at ZPCT offices and were facilitated by consultants from an organization called Leadership and Excellence (LEX). The purpose of the workshop was to build and enhance supervisory and leadership skills, communication skills, total quality management and team building skills through events aimed at creating a working environment that promotes team work. This activity was funded through the FHI funds. Provincial Program Review Meetings: All five ZPCT provincial offices held a two-day meeting to review the accomplishments of their respective provinces. The program’s objectives, approaches, targets, achievements, challenges and areas of improvement were the key issues discussed and presented at the meetings. The findings from the meeting contributed to planning for the ZPCT workplan and developing provincial work plans and budgets. These meetings were also attended by two Lusaka based staff members from different units. Program Officer Workshop: A one-day amendment development refresher meeting was held for all ZPCT Program Officers. The purpose of the meeting was to review the amendment process in order to complete amendments at scheduled times. ZPCT Quarterly Report (July 1 – September 30, 2008) 6 Human Resources: This quarter, ZPCT hired eleven staff to support the continuing program expansion. Some of these hires were to fill vacancies created by staff departures. The provincial positions were, two clerical officers for Luapula and North Western provinces, a senior finance officer, for Luapula, an associate finance officer for and a clinical care officer for North Western Province. The Lusaka new positions filled were a QA/ QI program officer, finance officer, senior programs coordinator, monitoring and evaluation officer, administrative assistant and a receptionist. There are still 25 vacant positions across ZPCT. Of these, ten positions are for drivers for the additional vehicles just procured for the provincial offices. The vacant positions will be filled next quarter. Decentralization of Provincial Offices: ZPCT senior management continues to monitor the provincial offices as they decentralize aspects of program management, technical and financial services.. All provinces are decentralized for monthly reports, community purchase orders and hiring of local support staff. Information Technology (IT) Capacity Building and System Maintenance: The ZPCT IT team continue to provide technical assistance to provincial offices on computer hardware, software, and use of applications. This is provided by help desk support officers in the five ZPCT provincial offices and three IT officers in Lusaka. The IT staff are funded through FHI G&A. During this quarter, IT focused on capacity building for the recently hired IT help desk officers. This was accomplished by rotating each helpdesk officer work through Lusaka for a week to further familiarize them with the ZPCT IT infrastructure. This was also an opportunity for the officers to resolve any issues needing clarification and for the IT officers to conduct the initial technical assessment for the help desk staff who were at the end of their probation period. The outcome from the capacity building activities was the need for IT to conduct some in-house IT refresher training for ZPCT staff in all the offices. A program is being drawn up for a training program to be conducted next quarter.

4.2. National Level Activities

ZPCT continues to provide assistance and leadership on technical and programmatic issues in all key areas at the national level. ZPCT actively participates in eight national technical working groups, as well as several ad-hoc implementation groups. Participation in national meetings and workshops ensures ZPCT input into national activities and enhances continued collaboration with the MOH and other partners. Meetings and workshops attended by ZPCT staff during this quarter are in the table below:

Technical Date Meeting/Workshop/Training Area September PMTCT Female Condom 2 (FC2) Dissemination Meeting: This dissemination 26, 2008 meeting was organized by ZHECT after an FC2 assessment was done in five provinces; Northern, Southern, Lusaka, Western and North Western. The purpose of the meeting was to provide information on research findings conducted on knowledge, attitude and practices of FC2. September General Consultative SITAN Workshop: This meeting was held to get input 25, 2008 from stakeholders on the 2008 situation analysis (SITAN) of children and women in Zambia. It was organized by UNICEF and the Ministry of Finance and National Planning. Different component studies of the 2008 SITAN were presented and discussed at this meeting. September PMTCT PEPFAR Zambia Partners’ Meeting on Food and Nutrition: This 24 to 25, meeting, held at RAPIDS, discussed current food and nutrition 2008 activities of PEPFAR implementing partners, provided GRZ and partner input to the content of the action plan, agreed on mechanisms for coordination among partners implementing food and nutrition activities and means to align USG activities with GRZ, and refined COP 08 food and nutrition activities as needed to ensure coordination and consistency with PEPFAR and GRZ guidelines.

September PMTCT USG PMTCT/MNCH Integration Meeting: This was a partners’ 16, 2008 meeting held at ZPCT to identify best practices in PMTCT/MNCH ZPCT Quarterly Report (July 1 – September 30, 2008) 7 Technical Date Meeting/Workshop/Training Area integration, discuss existing gaps and look at overlaps in programs. The meeting also highlighted the need of having global guidelines developed for integration, following up babies within 72 hours of birth and the roles TBAs should play in terms of PMTCT/MNCH integration. September PMTCT PMTCT TWG Meeting: The purpose of this monthly PMTCT TWG 12, 2008 meeting was to discuss current evidence relating to the use of HAART in pregnancy for all, irrespective of eligibility and place this in the context of clinical, logistical and social factors and provide national direction on the issue in the country. August 21, General Joint Mid Term Review (MTR) of the National AIDS Strategic 2008 Framework (NASF) thematic consultative 2008 meeting: The draft thematic reports discussed to provide input into the reports in order to improve quality. August 14, PMTCT PITC Implementation Survey and Pediatric HIV Clinical Mentorship 2008 Information Dissemination meeting: This meeting was held at UNICEF to disseminate information on the outcome of the PITC and pediatric HIV clinical mentorship survey that was conducted by in various parts of the country. It was reported that pediatric CT was being done mostly by lay counsellors; there was need to have full- time counselors at facility level; community level counseling needed strengthening; MOH needed to design an implementation package for PITC; counselling supervision require strengthening in most facilities; poor internal and external quality control systems were noted in some facilities. August 5, CT VCT Subcommittee Meeting: The meeting was held at CDC to 2008 discuss VCT day outcome and the work plan for 2008–2009 which is to include current national coverage, gaps, and strategy to fill in the gaps, reasons for low VCT uptake and how to increase participation. July 29 to PMTCT UNFPA/WHO Strategic Partnership (SPP) Africa Regional August 1, Workshop: This workshop was held in Lusaka at the Taj Pamodzi 2008 Hotel on Evidence Based Guidelines for Family Planning, Maternal and Newborn Health and STIs. The main objective of the meeting was to assist countries towards improving the quality of sexual and reproductive health care. July 25, PMTCT PMTCT TWG Monthly Meeting: The use of NVP pouches, adoption 2008 of revised DNA PCR new requisition forms and orientation of HCWs in the revised under five card were discussed at this meeting. July 9 to PMTCT PMTCT Lay Counselor Training Package Review Meeting: The 11, 2008 objective of the meeting, held at JHPIEGO, was to review and update the community lay counselor training package and development of a standardized mentorship tool for PMTCT pediatric HIV care following revision of the HCW training package. August 14, ART MOH review meeting of National Pediatric HIV/ART Mentorship in 2008 selected sites: This meeting was to review the mentorship that took place in four provinces which included ten ZPCT supported facilities. As a follow up, the MOH will convene another meeting to discuss further the roll out strategy at provincial and district level. September ART NAC 3rd Quarter stakeholders meeting with focus on ART: The 15, 2008 purpose of this meeting was to share partner achievements, challenges and to agree on the way forward. The MOH announced the new integrated management of adolescent and adult illnesses (IMAI) package to be finalized in the next quarter. It was also announced that the Zambian HIV guidelines are available on the website www.zambianhivguide.org. the next biennial meeting will be in February 2008. September ART Certification of ART providers and institutions: The objectives of the 16, 2008 meeting were to analyze the current situation on trainings and certification of ART providers and to build consensus on certification of ART trainings and providers. The MOH raised concerns on different types of training packages used and certificates issued and ZPCT Quarterly Report (July 1 – September 30, 2008) 8 Technical Date Meeting/Workshop/Training Area the need to grade them. A plenary session was held to answer relevant questions. A draft document will be circulated by the Medical Council of Zambia (MCZ) on the resolutions and recommendation of the meeting. September ART Review meeting on accreditation of ART sites: This meeting, held at 17, 2008 MCZ, was to conduct a review of recently assessed ART sites for accreditation. A total of 125 ART sites out of about 315 known sites had been assessed for accreditation. 41 sites countrywide had been accredited and only 22 had been issued with certificates upon payment of a fee. Concern was raised on one of the respective assessment domains to have a pharmacist at the facilities. This is not feasible considering the HCWs shortages. A meeting has been planned for review of contentious areas of accreditation tool on 17th October 2008. September ART National meeting on ART Continuing Medical Education (CME): This 17, 2008 meeting was held to finalize orientation and implementation program/schedule for the National ART CME. This is part of continuous professional development at facility level approved by MOH to be implemented by ZPCT and partners. Roll out is expected in the next quarter. September ART Special Experts Committee Meeting on Accreditation: The purpose of 22, 2008 this meeting was to discuss ART sites assessment reports from seven provinces and make recommendations for sites to be accredited. A number of concerns were raised such as assessors being strict and behaving like the ‘police’ and some DHMTs complained about the K250, 000 fee required for certificates of accredited sites being too much because they have many sites. The accreditation tool was cited as needing revision. September ART NAC 3rd quarter Theme Group Meeting: This was a consultative 25, 2008 meeting to discuss the national logistical management system and the newly launched training for pharmacists; data desegregation for elderly population living with HIV to be captured separately, and a sub committee was also formed to come up with a pre-ART package to assist HIV positive people delay initiation of ART or prolong their non eligibility. September ART National AIDS Strategic Framework (NASF) mid-term review: This 24th to 25th, was a review meeting to discuss reports following the mid-term 2008 review exercise of the 2006 – 2010 NASF. During this meeting it was stated that even though progress has been made in scaling up CT, PMTCT and ART; challenges have been identified including infection prevention in young people and discordant couples, ruling out HIV infection in the window period as well as meeting equity and geographical demands. The NAC secretariat is consolidating a report and will call dissemination meeting to present finalized report. July 2, 2008 ART, National HIV/AIDS Commodity Security TWG Meeting: At this one- Pharmacy day meeting the draft HACS strategy was reviewed and the launching plans were developed. The next steps included a final review meeting of the whole committee at the end of July before the strategy launch in August. July 24, PMTCT, National Early Infant Diagnosis (EID) Sub-committee Meeting: The 2008 Laboratory meeting, hosted by the MOH, discussed the key programmatic and logistical issues surrounding DNA-PCR testing. Discussions were shared between partners on the review of EID performance for the first and second quarter of 2008 (laboratory, courier network and trainings).

ZPCT Quarterly Report (July 1 – September 30, 2008) 9 Technical Date Meeting/Workshop/Training Area July 09 to ART, National annual cotrimoxazole and ARV drugs fore-cast and 11, 2008 Pharmacy quantification: The MOH, with support from the USAID/DELIVER Project and partners, conducted a workshop to forecast and quantify ARVs and cotrimoxazole national requirements. The purpose of the meeting was to review the data and to agree on the estimated national requirements for the period August 2008 to December 2010.

July 31 to ART, National HIV/AIDS Commodity Security TWG Meeting: ZPCT August 1, Pharmacy attended the two-day meeting at which the third draft HACS strategy 2008 was prepared and launch plans developed. The way forward included plans for budget preparation and final circulation to committee members before the strategy launch now planned for November. August 12, Pharmacy National ARVs Annual Forecasting and Quantification Review 2008 Meeting: This one-day meeting held at JSI has representation from the MOH and implementing partners. A trends analysis of the consumption of ARVs in the country was conducted and submitted consumption and morbidity data was used to update the forecasting and quantification of ARVs for the next year. August 28, Laboratory National Early Infant Diagnosis (EID) sub-committee Meeting: This 2008 was a follow up to the previous month’s meeting to discuss EID targets and the way forward with the program. Accountability issues around laboratory consumables were also discussed.

September QA/ QI The Quality of Health Care Course: ZPCT attended a training 22 – 26 workshop for the QI system which is being introduced and rolled out nationwide by the MOH with support from HSSP. This has led to the strengthening of links for QA/QI among these partners for closer collaboration with the MOH on sharing the evidence based ZPCT QA/QI system specific for HIV services in Zambia.

4.3. Technical Program Areas

The major activities undertaken during this quarter in each of the technical components are described below.

4.3.1 Counseling and Testing (CT)

CT services were available in 218 out of 219 reporting health facilities during this quarter.

4.3.1.1 CT Training

ZPCT has continued to strengthen the capacity of providers to provide counselling and testing services (both HCWs and community cadres). The following training courses for health care workers and ‘lay’ counselors were supported by ZPCT during this quarter: 61 HCWs from 15 districts of Luapula, Central and Northern Provinces were trained in basic CT. 57 lay counselors were trained in basic CT from ten districts of Central, Copperbelt and Luapula Provinces. 28 HCWs from nine districts of Luapula and Copperbelt Provinces were trained in child counseling. 30 lay counselors already trained in basic CT from 14 districts of Northern and North Western Provinces were trained in child counselling. 20 experienced counselors from ten districts of Central and North Western Provinces were trained in counseling supervision.

ZPCT Quarterly Report (July 1 – September 30, 2008) 10 19 already trained practicing counsellors (HCWs) from four districts of Central Province were retrained and updated in a refresher basic counseling and testing course.

4.3.1.2 CT Services

ZPCT continued to provide technical assistance to HCWs and lay counselors in ZPCT-supported facilities in the five supported provinces in order to strengthen CT services; maintain a high uptake of testing and collection of same-day results and strengthen the linkage to clinical care for ART. Most of the facilities in all the provinces supported continued to report a high uptake in general CT services with good linkages to care. The training of 57 more lay counselors in basic CT during this quarter has also reduced the waiting time for collection of results contributing to greater client satisfaction.

Technical assistance during this period focused on: Strengthening of routine provision of CT services: ZPCT continued to place emphasis on routine CT services at health facilities. At newly supported health facilities, the “opt-out” strategy was strengthened with the provision of same-day test results through creation of testing corners within the CT rooms. During this period, ZPCT continued to emphasize the need to have all clients testing HIV positive referred to clinical care for initiation of HAART for those who were eligible and continued care. Strengthening pediatric CT services for children admitted in care and in the under-five clinics: Routine offer of pediatric CT continued to be strengthened this quarter. The lay counselors that had been mentored in routine CT for children in the previous quarters continue to provide routine CT services in hospitals and under five clinics in selected facilities across the five ZPCT supported provinces. Currently, 23 hospitals and six health facilities have implemented routine child CT. Transport re-imbursements to HCWs and lay counselors working extra shifts at facilities providing routine CT for children has continued to be provided by ZPCT with support from CHAI. This quarter, a total of 6,699 children were tested and received their results for HIV. The CT services are also extended to the parents or guardians of the children using a family – centered approach. Monitoring and improving documentation of CT linkages to FP, STI and TB services: ZPCT continued to strengthen documentation in CT registers for services provided in newly supported facilities and maintain the service in other ZPCT supported facilities. Emphasis on offering all clients in TB, FP and STI clinics routine CT services also continued. The placing of, VCT/PMTCT integrated registers in TB and STI clinics enhances the documentation of the linkages to CT services for TB and STI patients. Quality assurance system: QA/QI tools continue to be administered in the ZPCT supported facilities as part of the ongoing monitoring of quality services. Strengthening referral linkages with HIV positive clients: ZPCT continues to strengthen linkage of all HIV positive clients to ART services in order to ensure that HAART was initiated for those that were eligible

4.3.1.3 Community Mobilization and Outreach in CT

During this quarter, ZPCT continued to work with community groups in order to create awareness of HIV/AIDS clinical services. The community groups were engaged to motivate community members to access CT services in facilities within their communities. A community purchase order (CPO) was developed in Kabwe with the Seventh Day Adventist HIV/AIDS club, a faith-based organization (FBO) to disseminate information to men, women, and youth on the benefits of being tested. Mobile CT services: During this quarter, ZPCT continued to provide mobile CT services in various locations of the facility catchment areas. Mobile CTs continue to increase the number of people accessing CT services, including those that do not see the need to go to the clinic to access these services. During this quarter, mobile CT services were provided in six districts bringing services closer and more accessible to the community. The table below provides a breakdown of the mobile CT activities.

ZPCT Quarterly Report (July 1 – September 30, 2008) 11

Males Counseled and Females Counseled and Children Counseled and Tested Tested Tested District Total # positive % Total # positive % Total # positive % positive positive positive Zambezi 246 3 1.2 123 6 4.9 34 0 0 Kabwe 245 24 9.8 295 30 10.2 41 1 2.4 Serenje 365 12 3.3 383 34 8.9 56 3 5.4 Chingola 62 0 0 43 4 9.3. 104 32.9 Luasnhya 5 0 0 23 4 17.4 324 10 3.1 Ndola 53 5 9.4 58 7 12.1 111 21.8 Grand total 976 44 4.5 925 85 9.2 670 19 2.8

4.3.1.4 Key Issues /Constraints in CT

Human resource shortages: continue to be a challenge and this has persisted in a number of facilities. ZPCT continues to address this issue by training additional HCWs and lay counselors to supplement HCWs’ efforts in providing CT services. ZPCT also continues to provide limited support for transportation to HCWs working extra shifts for CT. Shortages and interruptions in the supply of HIV test kits: continue to affect CT services negatively across the five supported provinces in both the old and newly supported facilities. The supply of test kits with short expiry dates from Medical Stores and occasional negative staff attitudes do contribute to stock outs. Some staff responsible for ordering test kits would sometimes hold on to requests for orders so that they travel to Lusaka themselves and get some allowance. ZPCT staff continue to work closely with facility staff and also conduct short in house trainings on logistics management in order to provide staff with skills in forecasting and ordering of commodities. Data collection for the uptake indicator for TB/HIV services: one of the indicators reported under TB/HIV services is the number of TB registered clients receiving CT services. From this indicator, it has remained difficult to isolate clients with unknown HIV status only from the total TB clients who are tested and recorded in the TB facility registers. ZPCT is attempting to address this challenge by liaising with MOH through the National TB TWG. Inadequate space for CT: this has persisted in some facilities especially in some of the children’s wards. ZPCT has continued to address this challenge through doing limited infrastructural refurbishments and continues to engage DHMTs and hospital managements in order to address the space problems.

4.3.2 Prevention of Mother-to-Child Transmission (PMTCT) of HIV

By the end of this quarter, PMTCT services were being provided in 209 ZPCT-supported facilities.

4.3.2.1 PMTCT Training This quarter, ZPCT supported the following trainings: Two trainings in basic PMTCT for 43 HCWs from ten districts and 30 facilities across Northern and Copperbelt Provinces. 20 lay counselors from four districts and 18 facilities in Central Province were trained in PMTCT. These community counselors have been placed in the health facilities and are already supplementing the HCWs’ efforts in providing PMTCT services. Following the standardization of the new six days PMTCT training package, 46 HCWs from seven districts and 33 facilities of Copperbelt Province were retrained and updated with new information on PMTCT. In addition, 174 HCWs from 16 districts across the five supported provinces were trained in DBS sample collection with a cumulative total of 837 trained so far across the five provinces.

ZPCT Quarterly Report (July 1 – September 30, 2008) 12

4.3.2.2 PMTCT Services

During this quarter, ZPCT continued to record a very high PMTCT uptake of above 90% in all supported facilities. The “opt-out” strategy continued to be operationalized in line with the WHO recommendations and the Zambia national protocol guidelines. As part of providing comprehensive PMTCT services, ZPCT continued to mentor newly trained staff as well as community PMTCT volunteers in implementing quality PMTCT services. ZPCT also focused on the implementation of quality PMTCT services through strengthening provision of more efficacious ARV regimens for PMTCT, same day testing and results, DBS and CD4 sample referral networks as well as hemoglobin monitoring for HIV positive mothers to facilitate initiation of AZT and mother baby follow ups through the under-five clinics.

Strengthening provision of same-day testing and results: ZPCT continued to promote “same- day HIV testing and results” through strengthening and creating HIV testing corners within the MCH departments as well as train more HCWs in skills to conduct HIV counselling and testing. Reflex CD4 count blood samples are collected on the same day of HIV testing to avoid inconveniencing and losing clients. Provision of more efficacious ARVs for HIV positive pregnant women: The WHO three tiered approach is emphasized in order to provide more efficacious ARVs for PMTCT. Blood is drawn for CD4 estimation and sent to the laboratory through the sample referral system. Depending on the come, HAART is offered to all eligible HIV positive pregnant women and is initiated at ART sites. Women not eligible for HAART are being offered short course prophylaxis (NVP on first contact, AZT at 28 weeks or soon after and an addition of 3TC during labour). The absolute minimum being offered to HIV positive pregnant women has remained single dose Nevirapine where there is no laboratory or haemocue machine to do HB estimation. Strengthening mother-baby follow-up as part of the continued pediatric HIV efforts: ZPCT continued to mentor facility staff in following up HIV infected mother-baby pairs through MCH services. HIV exposed babies continue to be identified at six weeks. Cotrimoxazole prophylaxis for PCP is initiated and DBS sample collected as part of the efforts to ensure early infant diagnosis of HIV infection through the HIV DNA PCR testing. During this period 326 HIV exposed children were provided with Cotrimoxazole prophylaxis. ZPCT continued to provide HCWs with training in DBS sample collection, handling, storage and transportation. Mentoring of trained HCWs on quality of DBS samples collected is ongoing. Linkage of PMTCT to family planning (FP): PMTCT FP referrals are routine in most facilities. ZPCT continues to encourage HCWs not linking FP to PMTCT to appreciate the importance of the linkages and hence take action by providing this much needed service. The emphasis on the linkages included FP counseling to ANC mothers attending ANC services and PMTCT counseling to women of child bearing age purely attending FP services.

4.3.2.3 Key Issues/Constraints in PMTCT

Limited human resource: Trained staff turnover has remained a human resource challenge. This is worsened by routine rotation/relocation of trained PMTCT providers. ZPCT continues to address this issue by training additional HCWs and community cadres in PMTCT. The trained community PMTCT counsellors supplement HCWs’ efforts in providing PMTCT services. CD4 count assessment for HIV positive women: Assessing CD4 count for HIV positive pregnant women continued to be a challenge in some facilities due to problems with the sample referral system, lack of transport and long distances in some instances. ZPCT continues to address the issue by providing motorbikes to some of the supported districts to strengthen the CD4 count sample referral system. Lack of hemoglobin estimation capabilities at some facilities: Some facilities did not have haemocue machines to enable them to estimate hemoglobin levels on HIV positive pregnant women. ZPCT is addressing this challenge by procuring additional haemocue machines for all facilities that need them.

ZPCT Quarterly Report (July 1 – September 30, 2008) 13

4.3.3 Antiretroviral Therapy (ART)

During this quarter, 96 of the 101 health facilities targeted for ZPCT assistance in this area provided ART services.

ZPCT continued providing technical assistance and mentoring in all health facilities targeted for ART with a focus on quality assurance and quality improvement of services. Expansion of the DBS referral and transportation system and links to PCR facility and the roll out of SmartCare in ART sites continue to be a priority. ZPCT is actively involved in preparing high volume ART sites with over 500 clients in all the provinces for assessments which will lead to accreditation of sites to support the national program spearheaded by the Medical Council of Zambia.

ZPCT continues to refurbish clinical care and ART rooms and provide the necessary medical equipment such as stethoscopes, thermometers, BP machines, diagnostic sets, weighing scales and examination couches.

4.3.3.1 ART Training

This quarter supported the following trainings:

121 HCWs participated in adult ART/OI trainings. 43 of these were from all the five provinces and 78 from Ndola Central and Nchanga North Hospitals were trained in refresher ART/OI.

101 HCWs were trained in pediatric ART. These trainings will be followed-up for on-site mentorship by ZPCT staff.

4.3.3.2 ART Services

At the end of this quarter, twelve additional sites began providing ART services: Katondo Health Center in Kabwe, Chisamba RHC in Chibombo, Chalata Health Center in Mkushi, Mpatamatu Section 26 clinic in Luanshya, Clinic 1 in Chingola and Kamfinsa Prison Clinic in Kitwe. Others are Kasempa Urban Health Center in Kasempa, St Kalemba RHC in Kabompo, Chiyeke RHC in Chavuma, Luwi Mission Hospital in Mwinilunga, Buchi and Hospital.

This brings the total number of health facilities providing ART services to 96, of which 49 are static sites and 47 are outreach sites, across the 34 districts. A total of 6137 new clients (including 447 children) were initiated on antiretroviral therapy this quarter. Cumulatively, a total of 62,128 clients were receiving antiretroviral therapy at ZPCT-supported sites; of these 4,227 were children.

ZPCT continues to focus on the issues outlined below: Implementation of SmartCare and mentorship in new ART protocols: ZPCT continued to roll-out the implementation of SmartCare and mentorship in new ART protocols in ZPCT-supported facilities. ZPCT staff, through scheduled technical assistance visits, followed-up the implementation of SmartCare. The implementation of smartcare is generally progressing well. This quarter, 37 health facilities started implementing new protocols bringing the total to 85 out of 96 ART sites. Seven of the facilities (five in Northern Province and two in Northwestern Province) have not yet initiated the implementation of the protocols because the laboratories in the two provinces lack the capacity to conduct chemistry tests particularly ‘’creatinine test’’ which is essential to assess renal or kidney function. Collaboration with Home-Based Care program: ZPCT has continued to provide ART outreach support to three home-based care centers supported by the Ndola Catholic Diocese; Chishilano in Ndola, Twatasha (TRAKK) in Kitwe, and Iseni in Chingola. This collaboration continued to expand in terms of client enrolment into care and treatment with 174 clients initiated on ART and 1,081 clients were monitored this quarter. The implementation of ART outreach services at Mpatamatu Home Based Care has been facing some challenges especially with transport. The District AIDS Task Force (DATF) vehicle which was to be used for the outreach has been unavailable and as a result, the outreach has not been active or taking place weekly as agreed in the last quarter. Most patients who were on treatment at this facility have been transitioned to the nearby Mpatamatu Section 26 Clinic under DHMT which started offering ART in the last quarter. However, ZPCT recently reviewed this arrangement with a view of renewing this MOU next quarter to run through March 2009. ZPCT Quarterly Report (July 1 – September 30, 2008) 14 Pediatric HIV/AIDS care and treatment: ZPCT continued to provide technical assistance and mentoring to scale-up pediatric AIDS treatment, with attention to routine or provider-initiated CT, timely initiation of ART, and cotrimoxazole prophylaxis. To scale up this activity, ZPCT has recruited pediatric HIV medical officers to specifically strengthen clinical mentorship and uptake in pediatric ART across the provinces. In addition to the two that were recruited last quarter, two more were recruited in this reporting period and the fifth has already been identified and will start work in the next quarter. Linkages with PMTCT services continued to be strengthened by ensuring HIV positive pregnant women who are eligible for treatment benefit from ART. In addition, HIV positive women who have delivered are being tracked to ensure their babies have the DBS (DNA PCR) test and those who are positive linked to HIV care and treatment. Ready-to-use therapeutic food supplements (RUTFs): ZPCT has continued to support the RUTF (also known as Plumpy’ Nut) program in ten selected high volume pediatric sites. This activity is in collaboration with CHAI and the MOH. CHAI supports the procurement of the Plumpy’ Nut, ZPCT coordinates the implementation and MOH provides the institutional and human resource support. RUTF is given to malnourished as well as children on ART. Children especially with severe malnutrition have shown dramatic improvement after taking Plumpy’ Nut. However, the improvement observed in the number of children does not correspond with the number being enrolled into the ART center. Monthly reports on the RUTF consumption data have been compiled and circulated to stakeholders and reflect a steady supply with no stock outs. In a few facilities demand apparently is low and staff are considering re-orienting HCWs in the wards so that they can refer malnourished children. Quality assurance/quality improvement: ZPCT continues to focus on quality assurance and quality improvement issues during the technical assistance visits to health facilities. ZPCT ensures the use of QA/QI tools, in collaboration with PHO, DHMT, and facility partners. ZPCT’s clinical care QAQI tools are in line with requirements of existing national documents such as the ART accreditation tool and the National ART Standard Operating Procedures (ART SOPs). After administration of these tools, a summary sheet highlighting the key problems at the facility is immediately given to facility staff as action points to improve quality of care. This feedback or response in QA/QI tools is being appreciated across most facilities. Accreditation of ART sites: ZPCT has continued to support ART sites to meet certain minimum standards so that these sites can officially get accredited by the Medical Council of Zambia as ART sites. This is being done by ensuring all the seven domains assessed for accreditation are satisfied. This activity is complimented by the administration of QA/QI tools. SOPs for ART, adherence counseling and post exposure prophylaxis (PEP): ZPCT has printed the ART SOPs and will jointly plan with MOH on the distribution and orientation of HCWs on the use of these resource/reference materials in the next quarter. Clinical seminars: ZPCT continues to promote and support clinical seminars for HCWs to discuss case studies and any new developments in HIV care including any critical clinical or programmatic issues related to the implementation of the HIV/ART program. Provision of reference materials: ZPCT has requested and procured more pediatric dosing wheels from CHAI due to demand from the facilities. CHAI has committed to providing 100 copies and will be delivered in the next quarter. In addition, other job aids such as ‘Creatinine Clearance Slide Ruler’, were delivered to facilities that were in need to complement the numbers that were previously given. Continuous Medical Education (CME): ZPCT has been liaising with other partners and MOH to introduce a capacity building program at the facility level for staff involved in ART patient care. The MOH has yet to give consent and approval for roll out of the program which will be done in phases. The orientation program for national, provincial and district coordinators will start next quarter. This will contribute significantly to preparing sites for accreditation.

4.3.3.3 Key Issues/Constraints in ART

The following constraints were faced in ART service provision: Patient monitoring/tracing: ZPCT continues to support adherence support workers (ASWs) to follow up patients on ART who have missed appointments or defaulted mainly by using bicycles supplied for this purpose. However, this is not always easy in rural districts where the distances between the facility and villages are vast.

ZPCT Quarterly Report (July 1 – September 30, 2008) 15 Increasing ART patient load against an established healthcare workforce: This has continued to be a challenge as most facilities are having difficulties coping with the number of patients (especially adults) that are enrolled into care. This is resulting in patients being given longer review dates and can it makes defaulter detection difficult. Baseline and monitoring tests: Some key biochemistry tests such as creatinine, a key test for using the new protocol drugs, need to be done for baseline and monitoring patients. If not done routinely due to equipment failure this may result in failure to implement new ART protocol drugs as highlighted above. Pediatric ART challenges: Implementation of routine CT in the wards has continued resulting in the increase in the number of children who test positive. However, a good number of these children referred to the ART clinic are lost as not all facilities allow initiation of ART on the ward which is desirable to minimize loss of children. Some facilities are unwilling to implement this strategy because staff in the wards are either not trained in ART or find ARV commodity management on the ward unmanageable. To ensure that all the children that are identified as HIV positive are linked to care, ZPCT has been introducing the usage of the SmartCare patient locator form as part of client records for children who test HIV positive. This will help with tracing children in the community in case they are lost before or after enrollment. The same system is being extended and utilized in follow up for those with uncollected DBS results.

4.3.4 Clinical Palliative Care

ZPCT is working across all health facilities to strengthen and improve palliative care for PLHA. During this quarter, all 219 reporting health facilities targeted for ZPCT assistance in this area provided clinical palliative care services.

4.3.4.1 Clinical Palliative Care Training

The national training curriculum for ART and OI management is combined. As described in Section 4.2.3.1, 121 HCWs from all the Provinces were trained in ART/OI and 101 in pediatric ART.

4.3.4.2 Clinical Palliative Care Services

Technical assistance in clinical care was provided to ZPCT supported sites in the five provinces. Palliative care strategies and activities are on-going and ZPCT staff, working with HCWs in the facilities, relevant DHMT and PHO staff and the community continued strengthening the following: Reporting of Adverse Drug Reactions (ADR): During the last quarter, ZPCT received feedback from the Pharmaceutical Regulatory Authority (PRA) on the possibility of working together to roll out usage of pharmaco-vigilance registers in health facilities. These registers are used to capture and document all adverse drug reactions and drug toxicities. PRA requested ZPCT to assist with printing of these documents and ZPCT is currently considering this request from and will estimate the number of registers required for its supported sites and the cost before the DTS can consent. However, in the meantime the clinical care and pharmacy units have continued to sensitize HCWs to document the ADRs. Diagnosis and management of opportunistic infections: The mentoring and supervision of HCWs in appropriate diagnosis and management of opportunistic infections continued this quarter, including pediatric HIV/AIDS cases. Scale-up cotrimoxazole prophylaxis: During this quarter, scale up was continued for both adults and children. Routine CD4 testing of all HIV positive TB patients: Facilitation of entry into clinical care and ART as required has continued from the last quarter. Community activities to increase awareness and benefits of HIV services and ART: These activities include messages through drama meant for the general population in public places like markets and also targeted where HBC programs have on record families or households that are affected by the HIV/AIDS and these are encouraged to go through CT.

ZPCT Quarterly Report (July 1 – September 30, 2008) 16 4.3.4.3 Key Issues/Constraints in Clinical Palliative Care

Referral linkages: ZPCT continues to strengthen the referral system within and between health facilities and other organizations offering health related services. Both the technical staff and the community mobilization/referral officers continue to work closely with HCWs and other cadres involved in the care of HIV clients to improve and strengthen referral systems and mechanisms by ensuring availability of referral documents, adequate documentation and filling of forms and registers and tracking of clients referred for various HIV/ART related services. Drugs for OIs: Cotrimoxazole for both prophylaxis and full treatment of OIs as well as drugs for treatment of tuberculosis continue to be readily available in most sites. The MOH, through JSI, will ensure that there is an adequate supply of the available essential drugs in all the public health facilities once the new drug logistic system is implemented. However, this has been a slow process and not all OI drugs are available, particularly cytotoxic drugs for treatment of Kaposi’s sarcoma and antifungal drugs (fluconazole and amphotericin B) for treatment of fungal meningitis.

4.3.5 Pharmacy Services

During this quarter, ZPCT continued to provide support for pharmacy services at 219 ZPCT supported health facilities. Ongoing activities include the provision of basic pharmacy equipment, furniture, and renovations to enhance pharmaceutical service delivery, training and technical assistance.

4.3.5.1 Pharmacy Training

This quarter, ZPCT trained 16 laboratory and 47 pharmacy health facility staff from Copperbelt, Central and Northern Provinces in commodity management for both pharmaceutical and laboratory commodities.

4.3.5.2 Technical Assistance in Pharmacy

ZPCT continues to provide technical support on the use of the updated ARTServ Dispensing Tool, a tool used by pharmacy staff to record data of clients on ART, including drug regimen, side effects, and drug dispensing dates at 53 sites. This will be expanded to all ART sites to be supported by ZPCT. Ongoing training of pharmacy staff in the use of ARTServ is planned to allow for staff rotation and workload reduction.

Technical assistance visits continue to be conducted to strengthen commodity management information systems in facilities offering ART services. ZPCT staff provided guidance on improving stores management including stock status update, storage space and conditions, timely ordering and collection, aggregation and proper use of commodity consumption data. The commodity inventory tracking tool, developed by ZPCT to assist in inventory control and tracking of commodities, is functioning well. In addition, technical assistance was provided to ensure that all facilities adhere to the ordering procedures as defined by the new ARV logistics management system.

Technical assistance visits were also focused on mentoring facility staff on good pharmacy practices, including dispensing, medication use, and enforcing adherence counseling to ensure better patient outcomes.

ZPCT continues to provide technical assistance to address non-submission of returns and data, which contribute to shortages of critical supplies and stock-outs. During this quarter, problems were encountered in a few facilities regarding access to selected supplies. Measures have been put in place to ensure that the affected facilities do not continue to experience these stock-outs which adversely affect service delivery.

The MOH is working in collaboration with CHAI and other partners to mitigate the negative nutritional impact of HIV and AIDS in infants and children by providing nutritional support in the form of RUTF, otherwise known as Plumpy Nut. These RUTF are being provided nationwide to HIV infected infants and children as a supplement to what is locally available and accessible. Through a well established system by MSL, this food supplement is supplied to the ART sites that have been identified as centers for the RUTF/Plumpy Nut support program.

ZPCT Quarterly Report (July 1 – September 30, 2008) 17 ZPCT is working to coordinate this program in its support areas in ten sites. Records are maintained well and enrollment criteria is being followed. During the quarter, ZPCT staff conducted re-orientation of selected facility staff in the implementation of the program, and ensured that all sites receive and display the job aides. The guidelines have still not been finalized, as MOH and other partners are still reviewing them. In addition, it has been noted that supplies have not been adequate to ensure full supply to all the facilities implementing the program nationally. Hence, until the MOH secure adequate funding to ensure uninterrupted and adequate supply of the RUTF all plans to further roll-out the program have been put on hold.

4.3.5.3 Guidelines and SOPs

ZPCT continues to distribute and promote the use of the Zambia ART Pharmacy SOPs to the facilities, and focuses on providing technical assistance to sites to ensure that work is being done according to the guidelines and SOPs. ZPCT facilitates the site-specific adaptation of these SOPs in line with GRZ policy. However, in line with the launch and dissemination of the new ART guidelines and the need for the inclusion of the new ARV logistics system procedures and forms, the Zambia ART Pharmacy SOPs need to be updated. After discussions with the MOH, the review process is underway. This process was meant to have been completed during this quarter but after a review in the approach and methodology, the exercise will now be completed next quarter with more participation from MOH and the stakeholders in the process. Once complete, the new SOPs will be distributed to all ZPCT static ART sites, and selected outreach ART sites.

The pharmacy services QA/QI tools continue to be administered at ZPCT-supported sites. Implementation of the tools plays a key role in monitoring the quality and sustainability of services, as well as building capacity within health facilities and DHMTs. A recurrent issue confirmed by the QA/QI tool is the critical shortage of qualified pharmacy staff in various health facility pharmacies. These results are shared with the DHMTs in the hope that they would move to place appropriate staff at the affected facilities.

4.3.5.4 Key Issues/Constraints in Pharmacy Services

ZPCT is committed to working with partners in the provinces, districts, and facilities to ensure an adequate supply of HIV-related commodities for provision of services. The following are challenges faced in meeting this goal. Medical Stores Limited logistics constraints: Occasional lapses in the transport system at MSL combined with some order delays from the districts continued in this quarter and led to requests for ZPCT assistance to transport critical supplies to support sites. However, this is only possible when there is pre-arranged travel to these destination sites. ZPCT is constantly working with facility staff to ensure that orders are submitted according to the delivery schedule requirements that MSL has issued. This has reduced the number of stock out experienced at the facilities. Lack of qualified staff in the facilities: Shortages of trained staff greatly compromise the quality of service delivery in the facilities. Working with DHMTs and facilities to implement the transport reimbursement system for staff working extra shifts has greatly improved this situation. This system has also greatly benefited the ART outreach program where pharmacy staff form part of the team that provides outreach services to remote facilities. Inadequate supply of commodities: An uninterrupted supply of commodities ensures continued service delivery across all elements of care. ZPCT actively participates in national level forecasting and quantification activities to ensure that the facilities’ needs are taken into account. Storage space: As ART services expand, there is an increased need for space in pharmacies to store ARVs and other commodities under proper storage conditions. ZPCT continues to assist through the provision of minor refurbishments to facilities, such as adding shelves, lockable cabinets and air conditioners which has helped improve the situation in targeted facilities. Equipment maintenance: The availability of fully functional equipment, such as computers and air conditioners, is an important aspect to provision of quality HIV/AIDS services. Breakdown of this equipment, particularly air-conditioners, affects the quality of service delivery. ZPCT is continuing to repair or replace this equipment if needed, and is working with the MOH on instituting equipment maintenance contracts with the vendors of this equipment.

ZPCT Quarterly Report (July 1 – September 30, 2008) 18 4.3.6 Laboratory Services

ZPCT is currently strengthening laboratory services in 111 facilities by providing technical assistance, supporting renovations, equipment maintenance, training and procurement of equipment. 85 of these laboratories are now fully operational. Technical assistance is routinely provided to support laboratory needs including additional ART sites (both static and outreach).

PCR Laboratory: The DNA/ PCR laboratory which was developed with the aim of increasing access to early infant diagnosis of HIV, is functioning well. The laboratory serves as a referral center for the five ZPCT-supported provinces. ZPCT has continued to provide technical assistance to focal persons to ensure proper DBS collection, packaging and transportation of the specimens to the testing centre. ZPCT has also since taken up responsibility for transportation of MSF DBS specimens from Kapiri Mposhi to ADCH PCR laboratory.

4.3.6.1 Laboratory Services Training

16 laboratory staff were jointly trained with 47 pharmacy health facility staff from Copperbelt and North Western Provinces in commodity management for both pharmaceutical and laboratory commodities.

In addition, a Joint National Bacteriology Training (co-funded by ZPCT, CDC and MOH) was held in Ndola at the Ndola College of Biomedical Sciences from 14 – 17 July, 2008. Nine staff from ZPCT supported facilities were trained.

4.3.6.2 Technical Assistance in Laboratory Services

ZPCT staff continue to provide technical assistance in laboratory services to all ZPCT supported health facilities throughout the five target provinces. The specimen referral system for CD4 is generally operating well in most sites for both CT and PMTCT clients resulting in continued increase in the number of ART clients which has significantly increased laboratory workload. Special attention is being paid to performing internal quality control when the materials are available and where materials are not available, facilities are encouraged and mentored to prepare their own quality control materials.

ZPCT provincial technical officers continue to provide technical assistance to improve commodity management systems for laboratory services at all ZPCT-supported health facilities. Technical assistance in this area focuses on quantification, timely ordering and storage of commodities.

ZPCT continued to provide technical support on the use of the Laboratory Management Information Systems (LMIS), a tool used to record test data of clients on ART and adopted by the MOH, at seven health facilities. The tool is working well and is being regularly modified with feedback from users.

The QA/QI tool for laboratory continues to be implemented at all ZPCT-supported hospital sites. A recurrent issue confirmed by the QA/QI tool is the critical shortage of trained laboratory technologists in nearly all health facility laboratories. These results are shared with the DHMTs and Hospital Management Teams. ZPCT will continue to provide transport reimbursements to partially alleviate this problem.

PCR laboratory: ZPCT staff continued to provide routine technical assistance and mentoring in quality DBS collection, packaging and transportation to district hubs in the supported districts.

4.3.6.3 Guidelines/SOPs

ZPCT continues to promote and monitor the use of the Zambia ART laboratory SOPs to facilities with laboratories, providing CT, PMTCT and/or ART services. However, in line with the launch and dissemination of the new ART guidelines, the Zambia ART laboratory SOPs were revised in the second quarter and are not yet in circulation. This was facilitated by the Ministry of Health.

The Internal Quality Control (IQC) guidelines previously developed are being piloted in sites with CD4 equipment. Once this document is finalized and will soon be submitted to MOH for approval..

ZPCT Quarterly Report (July 1 – September 30, 2008) 19 PCR laboratory: ZPCT has developed SOPs outlining the techniques of DNA extraction from DBS, general laboratory guidelines, a bio-safety manual, proper use of PCR equipment and criteria for rejection of specimens. These draft documents are currently in use in the laboratory and have been submitted for review by the HIV DNA PCR laboratory subcommittee of the Early Infant Diagnosis TWG. The final step of compiling one set of national guidelines for use in all the laboratories that implement HIV DNA PCR analysis in the country is still pending.

IQC monitoring continues with each test batch. In addition, the PCR laboratory participates in the CDC Proficiency Testing External Quality Assurance Program. Under this program, CDC Atlanta supplies participating laboratories with external control low positive, high positive and negative DBS specimens which are also included in every run with the Roche controls. Ten DBS specimens with unknown HIV status are also sent with every batch and when tested, the results are submitted back to CDC for evaluation. The second batch of controls and unknown specimens from CDC were received and tested in June, results were sent back to CDC before the deadline via email and postal mail. Feedback from CDC showed 80% success in the EQA tests performed in this quarter owing to two specimens which showed indeterminate results. However, on repeating the test according to instructions from CDC, correct results were obtained. Initial failure was attributed to post-amplification contamination which has been controlled.

4.3.6.4 Specimen Referral System

The specimen referral system which provides off-site support to facilities with limited or no laboratory capacity that ZPCT developed and implemented continues to function well. The system is functional with 111 health facilities referring specimens to 40 facilities with CD4 equipment across 32 districts. ZPCT staff continue to monitor the usefulness and quality, as well as to strengthen the specimen referral systems. ART sites without CD4 equipment, as well as the outreach sites, also refer specimens to the nearest facility with CD4 equipment. Specimens for baseline and monitoring investigations, chemistry and hematology analysis, are also being referred.

In addition, an assessment of the specimen referral system is scheduled to be conducted during the next quarter. The effectiveness of the system will be evaluated and results shared with other partners.

PCR laboratory: The PCR laboratory continues to serve as a referral center for the five ZPCT-supported provinces. During this quarter, all five provinces sent in dry blood spot (DBS) specimens for analysis. The specimen referral system has been expanded to transport dry blood spot samples from health facilities offering MCH services in the five target provinces to Arthur Davison Children’s Hospital for early infant diagnosis of HIV in children less than 18 months old. Samples are being batched at the district hubs and transported by Express Mail Service (EMS) operated by the Zambia Postal Service to ADCH PCR Laboratory in Ndola. Trainings in DBS preparation, packaging and transportation for referral to ADCH for the DNA PCR test have continued to be conducted by PMTCT and Lab and Pharmacy technical staff.

A total of ten laboratory technologists and scientists have been trained to date. Eight of the trained staff support the ADCH PCR laboratory on a rotational basis and one is working full-time at the laboratory. One laboratory cleaner has also been trained in Health and Safety in Pathological Laboratories and another is scheduled to be trained next quarter to provide relief when the other staff in unavailable.

A total of 2,039 DBS specimens were received this quarter from 152 facilities (29 are non ZPCT supported facilities) in 36 districts (3 are non ZPCT supported) in the five provinces. 2,060 specimens were tested and these include the backlog from last quarter. The remainder of the specimens will be tested next quarter.

4.3.6.5 Equipment and Reagents

During the quarter under review, the following is the status of laboratory equipment: CD4 count equipment: CD4 equipment is functional in all facilities, with a few challenges: The FACSCount at Mufumbwe was repaired and is functional. The FACSCount at Hospital still has a malfunctioning printer. BD does not have spare printers in the country office and is yet to order one for replacement.

ZPCT Quarterly Report (July 1 – September 30, 2008) 20 The automatic micropipettes for use on the FACSCounts for Hospital and Hospital developed faults and have since been brought to Lusaka BD office for repair. The Kasama FACSCount was repaired and reinstalled at Kasama General Hospital and the FACSCount originally procured for Hospital has since been withdrawn from Kasama General Hospital and is at Kasama ZPCT office awaiting reallocation and installation at Luwingu District Hospital. The FACSCount originally procured for Chiyeke RHC ( in Northwestern Province) will be reallocated to Puta RHC in District in Luapula Province to try and alleviate the problems being encountered due to limited access to CD4 testing in the district. A replacement will be procured for Chiyeke RHC and this will be placed once the refurbishments at the laboratory are complete. The UPS for the Nakonde FACSCount which blew up has since been replaced and dispatched to the Province.

A FACSCalibur was successfully installed at Kabwe General Hospital. Chemistry analyzer: Eight Humalyzer 2000 instruments procured from Biogroup for the various facilities are yet to be installed. These are for health facilities in Copperbelt (Ipusukilo, Kavu, Bulangililo, New Masala, Twapia and Kawama), Northern ( Hospital, and North Western (Zambezi District Hospital). The equipment installation process has been started and is expected to be completed next quarter. Hematology analyzer: The UPS for the ABX Micros 60 at Nakonde Rural Health Center has been procured and dispatched to the province. The ABX Micros 60 at Mansa General Hospital was repaired and calibrated and is functional. The ABX Micros 60 for Chiyengi was also upgraded to an 18 parameter instrument from the original eight parameter. Seven Sysmex pocH-100i were procured from Biogroup but not installed due to ongoing refurbishments of laboratories at the time equipments were received. The vendor will be contacted to install the equipment at six health facilities in Copperbelt Province (Ipusukilo, Kavu, Bulangililo, New Masala, Twapia and Kawama) and Mbala Urban Clinic in Northern Province.

ZPCT supported sites access reagents procured by GRZ and stored at MSL. Currently all reagents are available in sufficient quantities at central level to be accessed by facilities using the national logistic system. PCR equipment and reagents: All the equipment procured for the PCR laboratory at ADCH, except for the backup equipment, distiller, autoclave and purifier, has been installed and is working well. The equipment will be installed when the ongoing refurbishments of the future development room are completed.

All DNA PCR laboratory consumables for use in the laboratory at ADCH have been procured by ZPCT to date. However, Medical Stores Limited (MSL) is now stocking laboratory consumables packaged as the Roche Laboratory Consumables Kit. These kits are procured by Clinton HIV/AIDS Initiative (CHAI) and ADCH PCR Laboratory has begun accessing these stocks through the national system. The contents of these kits however do not cover the full needs of the laboratory and so ZPCT will continue to supplement. The PCR reagent kits (Roche Amplicor version 1.5) and DBS Collection Kits continue to be procured through the agreement with CHAI, stored at MSL and distributed to the facilities by MSL or with assistance from ZPCT where MSL is unable to distribute for one reason or another.

4.3.6.6 Key Issues/Constraints in Laboratory Services

ZPCT is committed to working with its partners in the provinces, districts, and facilities to ensure an adequate supply of HIV and ART-related commodities for provision of services. There are challenges in meeting this goal. Late submission of aggregated data: Submission of aggregated data on HIV-related commodities (e.g. HIV rapid test kits) from DHMTs to central level has improved while a few ZPCT Quarterly Report (July 1 – September 30, 2008) 21 DHMTs continue to be a challenge especially in Luapula Province due to the presence of UNICEF PMTCT increased demand. Stock outs have reduced but are still experienced at a few facilities. ZPCT is continuing to work with the DHMTs to build capacity at the district level to eliminate the delays. During routine technical assistance visits, problem analysis at the affected site is carried out to identify the root problem and solutions provided by the facility staff themselves so that they appreciate the challenge. Lack of qualified staff in the facilities: Shortages of trained staff have continued to compromise the quality of service delivery in the facilities. Although the MOH has embarked on posting laboratory graduates to hospitals and health centers, the challenge remains to be the retention of these graduates in these facilities. ZPCT continues to work with DHMTs and facilities to improve this situation by providing transport reimbursements to staff who work extra shifts. Supply of commodities: There has been a great improvement in the availability of reagents and most facilities are accessing supplies. The Supply Chain Management System (SCMS) project working with the MOH is in the process of planning a roll-out after the evaluation of results from the pilot centers for the new logistics system for laboratory commodities. Maintenance of diagnostic equipment: Routine preventive maintenance of diagnostic equipment is an issue and is still not being done even with MOH vendor contracts in place. This results in frequent equipment breakdowns thereby interrupting laboratory testing in the facilities. ZPCT in collaboration with the vendors/suppliers (Biogroup, BD and SG) trained the ZPCT laboratory staff in preventive maintenance to deal with minor faults and only call the engineers for major issues. This has helped to curtail the long turn-around time for equipment maintenance. Specimen referral systems: Overall, the specimen referral system is working well, but has continued to occasionally being affected by distances and the development of faults on the CD4, hematology or biochemistry instruments. ZPCT continues to find innovative ways of addressing these gaps, including using DHMT vehicles to transport specimens and refer samples to where CD4 instrument is functional. DBS specimens: The PCR laboratory is receiving specimens from non-ZPCT supported facilities in the five provinces. ZPCT working with the MOH/CHAI has been training non ZPCT supported sites in DBS preparation, packaging and transportation. Quality of specimens has improved. The challenge is the transportation system and the receipt of samples without requisition forms. Samples without requisition forms also cannot be logged into the PCR laboratory database because of the missing patient information. ZPCT has continued working with the DHMTs concerned to provide training and mentorship to these facilities. In addition, there have been delays in collection of DBS packages from hubs due to issues with EMS. Discussions are still ongoing with EMS, the courier service, to resolve this. ZPCT will continue to utilize EMS and switch to Post Courier, the provider identified by the MOH once the amount pre-paid by ZPCT to EMS is depleted.

4.3.7 Monitoring and Evaluation (M&E)

4.3.7.1 M&E Training Monitoring and evaluation modules were conducted as a part of technical trainings during this quarter. The M&E modules which cover record keeping and reporting for respective technical areas were offered to 428 participants undergoing technical trainings in CT, PMTCT and ART from ZPCT supported health facilities. Of these, 141 were trained in ART and clinical care, 138 were trained in counseling and testing, and 113 were trained in PMTCT. In addition, 14 HCWs and five data entry clerks were trained in the SmartCare system.

4.3.7.2 Technical Assistance in M&E During this quarter, ZPCT continued to provide support to the PCR laboratory to resolve observed data gaps.

ZPCT also facilitated the training in SmartCare in Nchelenge district to replace the FUCHIA systems developed by Médecins Sans Frontières (MSF) to necessitate the transition to SmartCare as planned. The deployment of the SmartCare system continued during the quarter under review. Further, ZPCT in collaboration with MOH conducted a joint TA to monitor quality assurance and quality control of the migrated data to SmartCare in Kabwe.

In the quarter under review, ZPCT conducted data audits in the five provinces for the period October 07 to August 08. The report will be ready during the month of October 2008. Lusaka M&E ZPCT Quarterly Report (July 1 – September 30, 2008) 22 staff also participated in provincial program review meetings for Copperbelt and North-Western provinces.

4.3.7.3 Key Issues/Constraints in M&E

The implementation of the automated SmartCare system was slowed in a number of facilities due to constant power cuts. The power problems still exist because the power utility company is yet to resolve this nation-wide problem. The delay by the MOH to grant ZPCT access to patient-level data electronically delayed the commissioning of SmartCare as the reporting tool at sites where the migration has been completed. The patient level access is necessary to provide a basis to reconcile the electronic reports with those from the paper-based ARTIS currently in use. However, this permission has now been granted and preparatory work began towards commissioning of SmartCare as the reporting tool at supported sites. The soon to be retired ARTIS registers are not available for those ART sites which are not ready to start using SmartCare due to lack of electricity and other considerations. The ARTIS registers are also still required at the ART sites running SmartCare until the old system is officially retired.

4.3.7.4 ZPCT Indicators/Results

The following table shows service statistics and related data through September 30, 2008 from ZPCT-supported sites. It is a summary of key indicators for all ZPCT activities from all facilities. The training statistics for health care workers and lay counselors who directly provide services in all the program areas are also presented.

Services in Health Facilities Receiving ZPCT Support Achievements (May 1, 2005 to September 30, 2008) Workplan Cumulative Indicator Quarterly Achievements Achieve (1 Oct 07 to LOP (1 Jul 08 to 30 Sep 08) ments 30 Sep 08) Percent Achievement (1 Oct Achievement s 07 to 30 (1 May 05 to TARGET FEMALE MALE TOTAL Sep 08) 30 Sep 08) CT Service outlets providing CT 216 21 Persons trained in CT 680 198 614 90% 1,606 Persons receive CT 54,000 21,039 19,820 40,859 152,688 283% 315,121 services PMTCT Service outlets providing 199 209 PMTCT Persons trained in PMTCT 400 111 480 120% 920 Pregnant women provided with PMTCT services, 84,000 34,783 34,783 119,004 142% 236,566 including CT Pregnant women provided with a complete course of 15,750 4,254 4,254 12,630 80% 23,310 ART prophylaxis Basic Health Care and Support Service outlets providing clinical palliative care 216 219 services Service outlets providing general HIV-related 216 219 palliative care Persons provided with OI management and/or 66,690 48,736 34,972 83,708 87,771 132% 92,457 prophylaxis Persons provided with 66,690 48,736 34,972 83,708 87,771 132% 92,457 general HIV-related

ZPCT Quarterly Report (July 1 – September 30, 2008) 23 Services in Health Facilities Receiving ZPCT Support Achievements (May 1, 2005 to September 30, 2008) Workplan Indicator Quarterly Achievements (1 Oct 07 to (1 Jul 08 to 30 Sep 08) 30 Sep 08) palliative care Persons trained to provide 200 222 528 264% 1,555 general HIV- related care Treatment Service outlets providing 96 90 ART services Health workers trained in 200 222 528 264% 1,555 ART New clients receiving ART 15,600 3,618 2,519 6,137 23,453 150% 63,072 Total clients receiving ART 51,300 37,190 24,938 62,128 62,128 121% 62,128 Pediatric Treatment Health workers trained in 150 101 187 125% 551 pediatric care New pediatric clients 1,560 185 262 447 1,688 108% 4,439 receiving ART Total pediatric clients 5,130 2,082 2,145 4,227 4,227 82% 4,227 receiving ART TB and Care TB infected clients receiving 7,000 665 779 1,444 5,190 74% 11,400 CT services HIV-infected clients attending HIV care/treatment services that 4,300 491 560 1,051 4,261 99% 7,776 are receiving treatment for TB disease (new cases)

Laboratory Infrastructure

Number of laboratories with capacity to perform 1) HIV 41 81 tests and 2) CD4 tests and/or lymphocyte tests Number of individuals trained in the provision of 60 200 333% 318 lab-related activities Number of tests performed at USG-supported laboratories during the reporting period: 1) HIV 372,254 184,217 671,197 180% 1,249,311 testing, 2) TB diagnostics, 3) syphilis testing, and 4) HIV disease monitoring

ZPCT Quarterly Report (July 1 – September 30, 2008) 24 4.4. Community Mobilization and Referral Networks

4.4.1. Working with Local Community Groups

During this reporting period, ZPCT collaborated with health facility staff and community groups including faith-based organizations to conduct community mobilization for HIV/AIDS services.

In an effort to continue supporting faith-based community activities, a Community Purchase Order (CPO) was developed in Kabwe with the Seventh Day Adventist HIV/AIDS Club, a faith-based organization (FBO) to disseminate information to men, women, and youth on the benefits of being tested. The purpose of these activities was to sensitize church members on the benefits of CT and PMTCT, and motivate them to access HIV counseling and testing. Prior to implementing activities at the camp site, the SDA HIV/AIDS Club members conducted motivational talks in 11 congregations of the Seventh Day Adventist Church in Kabwe east mission district. A total of 110 people were counseled and tested.

ZPCT continues to work with community leaders, neighborhood health committees (NHC), and health facilities to prioritize couples for service provision. CPOs were also developed with community groups to disseminate information to men on the benefits of being tested with their partners, the benefits of PMTCT interventions in keeping their partners and children healthy and to encourage male involvement make it more acceptable by the community.

In North Western province, community leaders oriented in referral tools and community job aides for HIV CT and PMTCT have started sensitizing the community members by disseminating HIV messages in the community. At St. Kalemba, leaders working with the facility staff mobilized and sensitized the community on the importance of partner notification and the implications that this has on treatment and care for women and children. As a result, a total of 80 couples were counseled and tested.

During the reporting period, ZPCT executed 18 CPOs with community groups as follows:

Province District Facility Group Copperbelt Ndola Kaloko Clinic New Masala Theatre Group Ndola Kaniki Clinic Kaniki Youth Friendly Chingola Chiwepala Clinic Reformed Church Community Support Group Luanshya Mpatamatu Clinic Mutende Home-based Care Luanshya Mpatamatu Clinic Mpatamatu Youth Friendly Mufulira Clinic 5 Kakoyo Clinic 5 Peer Educators Central Kabwe Mahatma Gandhi SDA HIV/AIDS club Kabwe Natuseko Natuseko HBC Kabwe Chowa Chowa HBC Kabwe Ngungu Ngungu HBC Serenje Serenje Urban Chililabombwe NHC Serenje Chitambo Chitambo HCC Luapula Kawambwa Mushota RHC Mushota NZP+ Samfya Lubwe Mission Hospital Lubwe Home-based Care Nchelenge Kabuta RHC Bumi Bwesu Youth Center North - Mufumbwe Matushi RHC Matushi Caring Mothers Western Mwinilunga Ikelenge RHC Ikelenge Community Mobilisation Group Mwinilunga Mwinilunga District Hospital St Anthony HBC

4.4.2. Community Mobilization

During this quarter, 57 lay counselors were trained in basic CT from Central, Copperbelt and Luapula through three trainings. This brings the total number of lay counselors trained to 422. In the next quarter, ZPCT will start placing lay counselors in the facilities immediately after they have completed their (practicum) field experiences and supervisors’ reports have been submitted. This is to expedite the process of placement of these lay counselors.

ZPCT Quarterly Report (July 1 – September 30, 2008) 25 ZPCT did not train any adherence support workers (ASWs) in this reporting period. Two trainings were implemented towards the end of the quarter and will be reported in the next quarter. One training included participants from the Copperbelt and Northwestern provinces and the other covered participants’ from Central, Luapula and Northern provinces.

4.4.2.1 Community mobilization activities planned next quarter

Community Volunteers Seminar: All five ZPCT provincial offices will be conducting a two day seminar for the community cadres (lay counselors, PMTCT counselors, adherence support workers) in their respective provinces in the next quarter. The objectives of the seminar is to allow sharing of experiences and challenges among the volunteers and the facilities, as well as to provide technical updates in their related areas of work. In addition, the seminar will also be an opportunity for ZPCT to recognize successes, either by individuals or facilities as a ways of showing appreciation of the work that is being done by these cadres. Mobile CT, CPOs and Stigma: The Provinical Offices will conduct 13 CPOs, 12 mobile CTs and three orientations on stigma reduction in the next quarter. World Aids Day Activities (WAD): The ZPCT provincial offices in collaboration with the DHMTs, the DATFs and key community groups will plan for and implement community mobilization activities through the CPO mechanisms to commemorate World AIDS Day. Key activities will include mobile CT services and community mobilization activities in the days preceding World AIDS Day, as well as on the day itself.

4.4.3. Referral Network

ZPCT provincial staff continues to collaborate with District Health Offices to strengthen existing referral networks and to establish networks in districts where they do not exist. A total of 20 referral networks have been established and 14 are in the process of development. During the reporting period, Kabwe referral network started data inputting in the newly established database to monitor and report on referral activities. ZPCT will continue to monitor and review the functionality of the Kabwe referral network database and determine whether it can be adapted for use by other networks. As a result of the established database, ZPCT will in the next quarter start documenting the Kabwe referral experience in initiating and strengthening district-based referral network for HIV- related services. For continuity and sustainability of referral networks and in order to strengthen the coordinating unit’s role in resource mobilizing for the functionality of the networks, ZPCT will be supporting referral review meetings in all five provinces in the next quarter. In Central, Copperbelt and Northern Provinces, NHCs continue to work with health facilities to refer clients as part of their routine community-based activities. However, the distance between the facility and district that NHCs represent is a challenge; it may not be feasible to have all the NHCS represented at the district level referral network. In Kasama, health facilities have continued using the district referral network form for internal facility referrals. At the ART clinics where the data entry clerks are placed, there has been an improvement in the documentation of referral of clients from PMTCT to ART. This has resulted in the strengthening of the intra/internal referrals and monitoring of HIV-infected pregnant women accessing the ART clinic. In Mansa, the district-wide referral network and the facility-based referral network established at Chembe RHC have continued collaborating within their areas of operation. The network members have been referring clients for the required services and are receiving feedback. The Mansa district-wide referral network has continued receiving support from network members such as stationery, printing of referral tools, transport, meeting venue including snacks and drinks for all meetings. During the reporting period, the Secretary for Traditional Healers Practitioners Association of Zambia (THPAZ) Mansa branch represented the association in monthly referral meetings. The stakeholders discussed the training of THPAZ practitioners in referral system to ensure that clients receive better services including HIV blood tests, and that the referral of clients with opportunistic infections that can easily be recognised by traditional healers such as TB and STI. The table below illustrates the status of referral networks in each of the ZPCT-supported districts:

ZPCT Quarterly Report (July 1 – September 30, 2008) 26

Province # Functional Networks # in Process of Development To Be Developed 3 1 Central 0 (Kabwe, Mkushi, Serenje) (Chibombo) 5 3 Copperbelt (Ndola, Chingola, Kitwe, (Luanshya, Chililabombwe, 0 Mufulira, Kalulushi) Lufwanyama) 4 2 1 Luapula (Kawambwa, Mansa, (Nchelenge, Chienge) (Milenge) Mwense, Samfya) 4 5 0 Northern (Kasama, Nakonde, Mpulungu, (Mpika, Mporokoso, Mbala,

Isoka) , Luwingu) 4 3 North Western (Kabompo, Zambezi, (Mufumbwe, Chavuma and 0 Mwinilunga, Solwezi) Kasempa) Total 20 14 1

4.4.4. Key Issues/Constraints for Community Mobilization and Referral Networks

The following challenges were encountered this quarter related to community mobilization and referral networks: Retention of lay counselors: Lay counselor’s retention has continued to be a challenge as some move to other organizations because of monetary incentives. 36 have since left across the five supported provinces. ZPCT continues to train more lay counselors to cover the gaps in HIV CT services. Large referral networks: referral network has continued to grow and coordination among members for provision of feedback and collection of monthly reports remains a challenge. The newly established referral network database is being used by members to input their referral activities reports. Unfortunately, the database is not generating reports, and ZPCT has contacted the consultant who worked on the database to rectify the problem. Fear of disclosure of status: Couples’ fear to disclose their HIV status still remains a challenge in some communities. It is difficult to target HIV exposed children for pediatric CT in cases where HIV status disclosure by the women to their spouses has not been done, and consent has not been sought from the parents. ZPCT continues to encourage PMTCT service providers to promote male involvement in PMTCT services through its community mobilization mechanisms which include the involvement of local/traditional leaders and community organizations using community purchase orders. Newly trained counselors: In North Western province, community mobilization activities could not be conducted in some sites during the reporting period because of delays in certifying counselors. Counselors are certified by the Ministry of Health (MOH) and World Health Organisation (WHO).

4.5. Quality Assurance and Quality Improvement (QA/QI)

During this quarter, ZPCT carried out several positive actions which will advance the profile and performance of QA/QI within all technical areas. This was in line with the activities undertaken last quarter to streamline and refine the QA/QI process. The QA tools were successfully revised through the collaboration between the QA/QI unit and each technical unit (PMTCT/CT, ART/Clinical care , Lab/Pharm). A consultant was engaged to create new data entry and analysis application software in CSPro (Census and Survey Data Processing Software) that corresponds with each of the revised QA tools. These improvements were aimed at making the QA/QI process more efficient, reliable and user friendly. The new tools and CSPro applications software for ART/Clinical care were used this quarter while the revised tools and software for the remaining technical areas are planned for use next quarter.

Following the revision of the QA tools and CSPro application software this quarter, a comprehensive re-orientation program was conducted for all technical staff at central level (ZPCT Lusaka office) on CSPro for data analysis. Re-orientation programs are planned for the provinces

ZPCT Quarterly Report (July 1 – September 30, 2008) 27

4.5.1 Administration of QA/QI Tools

ART/Clinical Care Tools: During this quarter ART/clinical care QA tools were administered in 46 ZPCT supported ART sites. The tools include the ART facility checklist and ART provider tools. Central to the provision of quality HIV/ ART clinical care, critical laboratory tests are required. These are biochemistry tests - kidney function tests (creatinine), liver function tests (ALT, AST) and hemoglobin. The tests should be conducted at baseline for ART eligibility assessment, and also for on-going patient monitoring. In addition, CD4 levels for immunological monitoring of patients at baseline and repeated at least every six months in line with Zambia National ART Guidelines must be done. ZPCT provides technical assistance to enable these national standards to be adhered to. Some quality problems common to the five ZPCT supported provinces affecting the quality of ART/clinical care services provided and presenting obstacles in meeting the standards in this quarter are; delays in initiation of ART due to delays in laboratory test results; stock outs of HIV test kits; screening of HIV positive patients for TB not being conducted routinely by HCWs; Lack of QA/QI committees in many facilities. In order to address these challenges, there is need for capacity building of HCW in providing HIV/ART care by mentoring, supportive supervision and training. In addition, laboratory services and referral systems at health facilities require strengthening. PMTCT/CT: During this quarter, the CT/PMTCT QA Tools namely facility checklist, CT provider tool, PMTCT provider tool and counselor reflection form were administered in 86 ZPCT supported health facilities. The CT/PMTCT facility tool was used to assess general aspects of site CT/ PMTCT operations, staffing levels, adherence to standards in both CT and PMTCT, and availability of registers and test kits. The CT and PMTCT provider tools were used by supervisors to assess the quality of the provider-client interaction as clients actually receive services, while the counselor reflection tool was administered as a self-reflection tool to identify areas of weakness. The increased mentorship by ZPCT technical staff has been instrumental in sensitizing trained counselor supervisors on their roles and responsibilities. However, Human resource shortages, lack of capacity building for CT counselors by supervisors and staff attrition continue to be a major challenge in sustaining quality gains made in supported facilities. Key areas identified for improvement in the next quarter include mentorship of CT providers and counselor supervisors. Laboratory infrastructure: Laboratory QA tools were administered in 50 ZPCT supported health facility laboratories. These tools asses the availability of essential job guides such as SOPs, laboratory safety and space, availability and maintenance of the lab equipment, quality control and sample referral systems. It also assesses lab record management and general lab management activities. The key problem hindering provision of good quality laboratory services faced this quarter were: lack of regular servicing and maintenance of lab equipment needed for critical tests resulting in many health facilities experiencing crippling breakdowns of lab equipment; QA/QI reports strongly state the need for ZPCT to urgently collaborate with lab equipment vendors to implement regular maintenance and repair schedules; frequent stock-outs and erratic supply of required lab test reagents like creatinine tests. Quality control (QC) procedures were not being regularly and routinely conducted in many laboratories. This includes both internal quality control (IQC) and external quality assurance (EQA). In addition, when conducted, IQC/ EQA results were not always recorded. As a result, there is need to strengthen laboratory commodity management. Pharmacy: Pharmacy QA tools were administered in 41 ZPCT supported health facility pharmacies. These were the pharmacy bulk store tool, dispensing and medication tool and pharmacy records tool. The tools asses the quality of the pharmacy room and space, commodity storage and management, pharmacy record management, dispensing procedures, counseling and records. The quality of ART pharmacy services is being affected by; lack of adverse drug reaction (ADR) report forms and ADR committees in health facilities creating a deficit in the management and reporting of ADRs for patients under HIV/ ART care and lack of key reference materials e.g. SOPs and also counseling checklists for ARVs in their dispensing area.

ZPCT Quarterly Report (July 1 – September 30, 2008) 28 Northern Province in particular reported lack of ARV prescriptions in the majority of their health facilities this quarter. Copperbelt province experienced stock-outs of some ARVs indicating that the commodity management and national logistics for ARVs requires strengthening. To improve pharmacy services, ZPCT is taking up the necessary steps to strengthen commodity management and national logistics for ARVs. Monitoring and Evaluation (M&E): The M&E facility QA tool was administered in 92 ZPCT supported sites. It assesses the quality and process of record management for ART and clinical care, CT and PMTCT services. However, due to the high number of ART clients, the lockable file cabinets supplied by ZPCT for storage of patient registers are inadequate. New cabinets are being procured to rectify this situation.

4.5.2 Facility Graduation Sustainability Plan

As part of its sustainability plans, ZPCT developed a graduation plan for ZPCT-supported districts to continue to provide good quality services in the absence of intensive external support. The graduation plan aims to transition supervision and technical assistance of districts implementing high-quality HIV/AIDS services from ZPCT to GRZ support without compromising service delivery or quality. ZPCT’s technical strategies and QA/QI tools will be used as the basis for assessing service quality in the targeted facilities. Graduation tools have been developed and are being used to establish comprehensive graduation plans by the provinces. However, since facilities eligible for graduation must maintain and sustain an acceptable standard in CT, PMTCT, clinical care, ART, pharmacy and laboratory services for a period not less than three to six months before graduation, and with the expansion to additional health facilities in the districts planned for graduation, the process has slowed down.

Taking these developments into consideration, each province aimed to graduate at least one district by September 30, 2008. However, this did not take place due to various challenges including inadequate HCW staffing, clinical care limitations, laboratory infrastructure and sample referral systems constraints discussed below. ZPCT in collaboration with the PHOs and DHMTs still have plans to work together to overcome these challenges and graduate these earmarked districts by the end of December 2008. The seven districts identified for graduation were Mkushi and Serenje (Central Province), Luanshya (Copperbelt Province), Samfya (Luapula Province), Kabompo and Mufumbwe (North Western Province) and Kasama (Northern Province). The graduation process will be rolled out as challenges are met enabling additional districts to be graduated in the next work plan period. ZPCT will continue to provide some financial assistance to graduated facilities to enable the provision of quality CT, PMTCT, clinical care and ART services with minimal supervision and technical assistance from ZPCT provincial and Lusaka offices.

Luapula Province: Samfya District was targeted for graduation. Constraints outlined were the need for regular servicing of lab equipment to improve lab services and new pharmacy staff not yet trained in ART commodity management. Northern Province: Kasama, Nakonde, Mpika and Chinsali Districts had been targeted for graduation. Constraints outlined were the need to improve lab services. Copperbelt Province: was planned for graduation. Laboratory service constraints were outlined as obstacles to graduation. These were long sample turn around times and untimely sample referrals, quality control procedures not adequately conducted and lack of sufficient laboratory technical staff to provide services. Several health facilities lack space for ART adherence counseling. North Western Province: Kabompo and Mufumbwe districts were targeted for graduation in North Western Province, however, it was not possible to graduate any districts this quarter owing to a number of constraints not yet resolved by the close of the quarter. In Kabompo District, gaps were the need to improve pediatric ART services, train staff in pharmaceutical management and record systems and strengthening of laboratory specimen referral systems. In Mufumbwe district, these were named as crippling shortage of HCW specifically lack of trained laboratory staff, and clinicians to provide ART/PMTCT/CT services. There was also the need to strengthen laboratory specimen referral systems and to accelerate refurbishments in the facilities to create adequate space for service provision.

ZPCT Quarterly Report (July 1 – September 30, 2008) 29 Central Province: Mkushi was earmarked for graduation. Several technical challenges prevented its graduation. These were lack of SOPs in the ART sites, no regular ART meetings and ineffective sample referral systems. Some sites ran out of HIV test kits and ART monotherapy was being practiced. The collection of DBS samples was not consistent. Serenje was also targeted for graduation. Constraints included absence of a clearly identified team leader for clinical care/ART, poorly functioning sample referral system and no regular ART meetings. The absence of a Pharm/Lab officer at the provincial office meant that QA/QI tools for the second quarter could not be done. Consequently, the monitoring of pharmacy and lab activities was not very effective. The graduation tools were not administered in the two quarters making it difficult to determine progress in this technical area in all districts.

4.5.3 Key Issues/ Constraints in QA/QI In addition to the constraints outlined in the previous sections, key challenges faced in the QA/QI system are as follows; Absence of QA/QI tools within MOH: ZPCT has developed tools adapted from the MOH SOPs and guidelines. The tools are being implemented at facility level in collaboration with the DHMT and discussions regarding adoption of standard QA/QI tools across the country are ongoing with the MOH. Feedback systems: Definite QA/QI feedback channels at higher levels than the health care workers interviewed are lacking. There is need to improve on this feedback process to health facility management, DHMT and PHO so that QA/QI system can bear positive results both at health facility and provincial levels. Graduation process: The graduation of health facilities enabling entire districts to be graduated by the end of December 2008 in line with the graduation plans remains a significant challenge. It is difficult for health facilities to attain high quality levels of service and maintain these levels in view of frequent staff movement, staff loss, and untimely response by relevant higher authorities. In addition, the graduation process requires full understanding and buy-in of DHMT/PHO in order to be accomplished. The challenge has been that understanding and buy-in have not been fully obtained. 4.6. Training

As part of the site preparation that ZPCT conducted jointly with the PHOs, DHMTs and facilities, training needs were determined for each facility. Training for facilities is planned and participants are selected in consultation with the PHOs, DHMTs, and facility management. Maintaining an adequate number of trained staff in the face of frequent staff transfers is an ongoing challenge in all districts. A recent communication from the U.S. Embassy outlined the training per diems allowed to pay for MOH staff. These per diems are in line with the FHI rates. The memo also stated that USG supported programs are not allowed to provide facilitation fees to MOH staff. This has decreased the rate of training since many of the MOH staff are not willing to conduct training without the facilitation fees. In attempts to address this challenging issue, ZPCT put out a call for private consultants and consulting agencies to conduct training in the areas of CT, PMTCT, ART/OI and clinical care. The challenge faced is finding non-GRZ individual consultants and agencies. Some of the training targets are still being met using ZPCT clinical officers who are qualified as national trainers. Using ZPCT staff as trainers has delayed implementation of training activities due to the amount of time they can spend mentoring staff at the facility. Additional training activities are planned for next quarter to meet the targets. During this quarter, staff from ZPCT-supported health facilities attended courses in basic CT (61 HCWs), child counseling (28 HCWs), counseling supervision (20 HCWs), PMTCT (43 HCWs), pediatric ART/OI (101HCWs). Thirty-six M&E staff and data entry clerks were trained in SmartCare software use and 50 data entry clerks were trained in data management. In addition, ZPCT trained 57 community volunteers in basic CT, 30 in child counseling and 20 in PMTCT. ZPCT also trained 174 HCWs in DBS collection, storage and transport.

Details of training for each program area are provided in Section 4.3 and in Attachment B, ZPCT Training Courses.

ZPCT Quarterly Report (July 1 – September 30, 2008) 30 5. ONGOING CHALLENGES

Human resources Staff capacity and availability at all levels within the provinces are below what is required, especially at the health center level. The addition or expansion of HIV-related services further strains the situation. In response, ZPCT has developed and implemented a transport reimbursement schedule to support HCWs who work extra shifts, as well as training and placing lay counselors, adherence support workers (ASWs) and PMTCT counselors to relieve HCWs counseling duties.

Training and support for HCWs Several challenges are inherent in training in Zambia. Training for PMTCT and ART/OIs must follow the Zambia national training curricula. These are both two-week courses which take staff from already short- staffed facilities for a long period. In addition to the service-related issues, this is also a considerable burden on the ZPCT budget. ZPCT has conducted in-house training courses and continues to work with MOH and other partners on alternative strategies and models for training, as well as cost-savings for current trainings.

Inconsistent supply of HIV commodities and drugs Although there have been improvements in supplies of HIV test kits, reagents, ARVs and other commodities, there are occasional interruptions to service provision due to erratic supplies. This situation is particularly challenging because there are so many points in the supply chain where a breakdown can occur. ZPCT works with staff in the facilities, and with the MOH, USAID/JSI/DELIVER and Supply Chain Management System (SCMS) at both the national and facility levels, on quantification, record keeping, ordering, and commodity management.

National guidelines, protocols, and SOPs ZPCT is disseminating key CT and PMTCT guidelines to facilities. Technical staff are working with the MOH and other partners on development of national SOPs for key procedures and has provided MOH approved job aids in CT, PMTCT, and ART/OI to ZPCT-supported facilities to enhance quality assurance and improvement. However, the job aids provided are insufficient and not always available in the facilities because HCWs take them home.

Implementing M&E systems in government facilities The MOH, both at the national and provincial level, is not willing for implementing partners to introduce additional reporting requirements in government health facilities. While most indicators required for ZPCT reports under PEPFAR are collected through the existing HMIS, there are a few missing indicators which require additional efforts. Data entry clerks were hired, oriented, and placed in ZPCT- supported ART centers and they have improved the quality of data and increased the sustainability of improved data collection methods being introduced. Additional data entry clerks are being recruited to provide support to the new ART sites. Data entry clerks are hired through the recipient agreements based on MOH salaries and benefits. The long term status of the data entry clerk positions is being discussed with the MOH.

Sustainability and quality of services As ZPCT expands into more districts and facilities quality assurance and sustainability become increasingly important and more challenging. ZPCT staff will continue to provide technical assistance and mentor staff at the facilities to ensure quality. ZPCT piloted QA/QI tools for all technical areas in each of the provinces and are working with facility staff and the DHMTs to establish routine QA/QI.

Strategies to respond to these challenges have been incorporated into the ZPCT work plan and are being addressed as implementation progresses.

ZPCT Quarterly Report (July 1 – September 30, 2008) 31 6. PLANS FOR THE NEXT QUARTER

A summary of the plans for next quarter is given in the table below. Besides the activities listed in the table below, ZPCT will continue to partner with MOH and other partner organizations at the provincial and district levels and with staff and management in the supported facilities.

Technical Area Planned Activity General Continue to provide human resource support to Lusaka and all provincial offices with a focus on strengthening performance management systems and staff motivation. Complete recruitment of key vacant positions. Complete amendments for 10 recipient agreements ending on December 31, 2008. Procure additional equipment and furniture for health facilities as identified through amendments. Continue to support PHO recipient agreements and support implementation of activities under these recipient agreements. Continue to carry out renovations under the new and amended recipient agreements. Monitor and support implementation of rural refurbishment for staff housing in Northern and North Western provinces. Pilot seminars for ZPCT-supported community volunteers (lay counselors, adherence support workers and PMTCT lay counselors) in Central Copperbelt and North Western provinces. Continue with implementation of stigma reduction activities, including training of facility staff to support implementation of stigma reduction exercises at ZPCT- supported health facilities. Strengthen the referral system including integrating the review of referral data during PHO and DHMT supervisory visits. Conduct regular program support visits to monitor program activities in all the five provinces. Collaborate with CHAZ on implementation and reporting of project activities and provide support and monitoring to assure quality. Develop transition/close-out plan by first week of November 2008. Participate in World AIDs Day activities. CT Provide technical support and capacity development to the Provincial Offices. Provide TA and mentoring to health facilities (each facility visited at least quarterly). Continue supporting the implementation of routine HIV counseling to strengthen CT within existing TB, STI and FP services in all facilities. Establish testing corners in all CT rooms in new facilities. Continue to strengthen the implementation of routine CT in the Paediatric wards of 25 targeted hospitals and the under five clinics in 10 other facilities. Continue to strengthen QA/QI implementation for CT in the existing sites and initiate in the new ones. Support mobile CTs in the five provinces in order to bring CT services closer to the rural populations. Participate in NAC CT Technical Working Group. CT, PMTCT Train 340 HCWs and community cadres in various CT trainings. Continue to provide mentorship to facility staffs in CT/PMTCT services provision, with attention paid to facilities with weak performing indicators. Continue supporting the provincial Offices with TA and capacity development PMTCT Ongoing facility staff mentoring. Continue to initiate (in new sites) and strengthen ( in old sites) mother baby follow up, including initiation of cotrimoxazole at six weeks. Strengthen provision of more efficacious drugs for (HAART, AZT &NVP) PMTCT (in old sites) and initiate this activity in the new sites and strengthen the linkages to ART services. Continue to strengthen the linkages for PMTCT and family planning services among ANC mothers and during the postnatal period especially for the HIV infected mothers. Strengthen the implementation of QA/QI systems for PMTCT services. Participate in the MOH PMTCT and Pediatric National Working Technical Group and the DBS/PCR stakeholders’ committee. Hold PMTCT/CT technical capacity building meeting with provincial staff. Train 100 HCWs and another 100 community cadres in PMTCT. ZPCT Quarterly Report (July 1 – September 30, 2008) 32 Technical Area Planned Activity Train 25 HCWs in DBS collection handling and storage trainings. Complete and strengthen operationalization of early infant HIV diagnosis using DBS/PCR in all facilities. PMTCT, Implement and monitor the DBS courier network; in addition, ensure the functionality Laboratory of the PCR laboratory for early infant diagnosis. Complete trainings of HCWs in dry blood spot collection, sample handling, storage and transportation and operationalize implementation of early infant diagnosis using PCR technology at additional health facilities. Strengthen sample referral system for CD4 analysis to enhance provision of more efficacious ARVs for PMTCT. Continue to follow up on review of SOP outlining the techniques of DNA extraction from DBS, general laboratory guidelines, a bio-safety manual, proper use of PCR equipment and criteria for rejection of specimens by PCR laboratory subcommittee for comparison with the other two PCR laboratories in the country. Laboratory Develop schedules for ZPCT staff to conduct periodic routine maintenance on laboratory equipment, based on equipment maintenance trainings conducted in previous quarters. Conduct trainings in ART Commodity Management for laboratory staff at ZPCT supported facilities. Conduct trainings in equipment use and maintenance for users at ZPCT-supported facilities. Procure and place 11 FACSCounts for CD4 analysis to increase the number of referral laboratories from 40 to 51. Develop indicators and tools for monitoring the sample referral and transportation system and IQC usage and conduct an evaluation of the system; Continue to monitor the use of the automated systems in laboratories at ART sites to enhance the process of accurate management of data i.e. patient information, test profiles, inventory management (the Laboratory MIS). Conduct a technical review and update meeting with provincial pharmacy & laboratory officers and Lusaka Office staff. Continue to participate in the national quantification exercises for laboratory commodities and HIV test kits to ensure that ZPCT facilities are included in the national commodities’ procurement plans. Continue to participate in the National Laboratory Services Strengthening Committee to ensure that ZPCT’s laboratory strategic approach is in line with the national objectives for laboratory services in Zambia. Provide technical assistance and mentorship to scale-up pediatric ART. Print and distribute the revised SOPs for ART, post-exposure prophylaxis and adherence when approved by the MOH. Support initiation of ART services to all newly expanded sites. Implement fast-tracking of reactive (positive) DBS results from ADCH to the provinces to provide follow-up care and treatment to children. Orient HCWs in ZPCT-supported sites to start generating SmartCare clinical reports (late pharmacy pick-up report, non-standard regimens report, ART failure report and CD4 monitoring report) to assist in review and improvement of quality of care of patients. Continue providing on-going technical assistance and mentorship to scale-up pediatric ART. ART Distribute the MoH approved SOPs for ART, post-exposure prophylaxis and adherence. Orient HCWs on the national SOPs for ART, Adherence Counseling and PEP Administer QA/QI tools in collaboration with health facility staff, DHMT and PHO Implement the facility based Continuing Medical Education (CME) programme in ART sites (with MoH and other partners). Provide technical assistance and mentoring on new national ART protocol guidelines and SmartCare system. Ensure children eligible for ART are provided with appropriate treatment, including cotrimoxazole prophylaxis. Strengthen the established comprehensive care centre for the family (parents and children) at Arthur Davison Children’s Hospital and replicate this model in other high volume hospitals.

ZPCT Quarterly Report (July 1 – September 30, 2008) 33 Technical Area Planned Activity Work with partners to organize the 3rd ART Update Seminar Facilitate participation of 35 HCWs from ZPCT supported ART sites in the 3rd ART update seminar. Support initiation of ART services to the remaining 5 of the expanded sites. Working with pharm/lab unit, implement fast-tracking of reactive (positive) DBS results from ADCH to the provinces to provide follow-up care and treatment to children. ART, Pharmacy Continue updating the ARV dispensing tool at ART sites where it is already installed, and install in all new ZPCT-supported ART sites once computer sets are delivered. Monitor the implementation of the RUTF (PlumpyNut) program and continue to work with MOH on the completion of the national guidelines. Once these are finalized, they will be disseminated to all ZPCT supported facilities implementing the program. Conduct trainings in ART Commodity Management for pharmacy staff at ZPCT supported facilities. Facilitate the printing of Adverse Drug Reaction reporting forms in support of the implementation of the pharmacovigilance program at ART centers. Roll-out the usage of pharmaco-vigilance registers to standardize reporting of adverse drug reactions. Monitor the implementation of the ARV logistic system in all ZPCT sites. Participate in the national evaluation of the PMTCT Drug Logistics System and collaborate with stakeholders in the re-design and roll-out of the new system. Participate in the national quantification exercises for ARVs and OI drugs to ensure that ZPCT facilities are included in the national commodities’ procurement plans. Contribute to the development of the National HIV/AIDS Commodities Security (HACS) strategic plan together with other implementing partners and the MOH. TB/HIV Integrate and strengthen the TB/HIV links through opt-out provider-initiated HIV testing and CD4 testing for all HIV positive TB patients to ensure effective management of co-infections through early and appropriate referral to ART. Community Implement at least 13 CPOs and conduct at least 12 mobile CT activities during WAD mobilization and week. Referral Conduct 3 stigma reduction trainings in all five provinces. Network All provinces to initiate development of referral network. Conduct community cadre seminars in all five ZPCT supported provinces. M&E Train DECs in the interpretation of indicators involving basic Clinical Care terminologies. Conduct a SmartCare QA/QC for aggregated data from all ZPCT supported health facilities. Conduct the semi-annual data audits in all provinces to ensure reliability of data reported and amend reports as needed. Implement a geographical information system (GIS) for use in data management, analysis and presentation. Conduct full M&E training for targeted districts for health information staff at the district level and selected hospitals. Hold ZPCT M&E technical update meeting. Design facility profile data collection template and collect facility profile data from the ZPCT-supported sites. Identify and assess ZPCT-supported health facilities which will need additional computers and/or DECs as patient load increases. QA/QI Administer client exit interviews for ART, pharmacy, and CT services, analyze their results and plan appropriate actions to improve quality based on their findings Collate and analyze QA/QI data collected to identify support needs for “poor performing” sites. Identify, encourage, support “high-performing ART sites” to get national accreditation status from the Medical Council of Zambia. Continue to support the revision and dissemination of national and SOPs for the laboratory, pharmacy, ART, PMTCT and CT services. Continue to provide technical assistance to the provinces on the systematic and regular use of all QA/QI and graduation plans. Strengthen procedures to ensure that collected data is analyzed, documented and disseminated on the quarterly basis to determine progress towards achieving benchmarks. Strengthen feedback mechanisms between provincial offices and supported facilities ZPCT Quarterly Report (July 1 – September 30, 2008) 34 Technical Area Planned Activity with the aim of fostering team work and partnerships in implementing a systematic QA/QI system. Continue to work closely with MOH focal person to institutionalize and develop a National QA/QI system for HIV/AIDS services. Selected districts across the five provinces have been identified for graduation and plans are being put in place to move this process forward. The districts, which will be gradated by December 30, 2008. Procurement Distribute 10 newly procured vehicles for the five provincial field offices. Distribute additional motorbikes procured for DHMTs and health facilities

ZPCT Quarterly Report (July 1 – September 30, 2008) 35 Attachment A: ZPCT Facilities

Central Province District Health Facility ART PMTCT CT Specimen CC Lab Referral Strengthen Initiate Strengthen Initiate Strengthen Initiate for CD4 1. Kabwe General Hospital 3 2. Mahatma Gandhi HC 1 3 3. Kabwe Mine Hospital 4. Bwacha HC 5. Makululu HC 1 6. Pollen HC 1 7. Kasanda Urban Health 1 Clinic Kabwe 8. Chowa HC 9. Railway Surgery HC 10. Katondo HC 1 11. Ngungu HC 1 12. Natuseko HC 1 13. Mukobeko Township HC 14. Kawama HC 15. Kasavasa HC 16. Mkushi District Hospital 3 17. Chibefwe HC 18. Chalata HC 1 2 Mkushi 19. Masansa HC 1 2 20. Nshinso HC 21. Chikupili HC 22. Serenje District Hospital 3 23. Chitambo Hospital Serenje 24. Chibale RHC 25. Muchinka RHC 26. Kabundi RHC 27. Liteta District Hospital 3 28. Chikobo RHC 29. Mwachisompola Health Demonstration Zone Chibombo 30. Chibombo RHC 31. Chisamba RHC 1 32. Mungule RHC 33. Muswishi RHC 34. Chitanda RHC 16 active 23 active Totals 3 13 14 20 29 5 34 3 planned 6 planned ART – Antiretroviral Therapy; CC – Clinical Care; CT – Counseling and Testing; PMTCT – Prevention of Mother to Child Transmission

Services have started 1 = Outreach ART Site Services are planned, but not yet started 2 = Facility has a laboratory but not yet functional *New facilities are indicated in red. 3 = Referral laboratory for CD4

ZPCT Quarterly Report (July 1 – September 30, 2008) 36 Copperbelt Province: ZPCT-Supported Services

District Health Facility ART PMTCT CT Specimen Strengthe CC Lab Referral Strengthen Initiate Initiate Strengthen Initiate n for CD4 1. Ndola Central Hospital 3 2. Arthur Davison Hospital 3 3. Lubuto HC 1 4. Chipulukusu HC 1 5. Chipokota Mayamba HC 1 6. Mushili Clinic 7. Nkwazi Clinic 8. Kawama HC 9. Ndeke HC Ndola 10. Dola Hill Urban Clinic 11. Kabushi Clinic 2 12. Kansenshi Prison Clinic 1 13. Kaloko Clinic 14. Kaniki Clinic 15. Kavu Clinic 1 16. New Masala Clinic 1 17. Pamodzi-Sathiya Sai Clinic 18. Railway Surgery Clinic 19. Twapia Clinic 1 20. Nchanga N. General Hospital 3 21. Chiwempala HC 1 3 22. Kabundi East Clinic 1 Chingola 23. Chawama HC 24. Clinic 1 HC 1 25. Muchinshi Clinic 1 26. Kasompe Clinic Kitwe 27. Kitwe Central Hospital 3 28. Ndeke HC 1 3 29. Chimwemwe Clinic 1 3 30. Buchi HC 1 31. Luangwa HC 1 32. Ipusukilo HC 1 2 33. Bulangililo Clinic 1 34. Twatasha Clinic 35. Garnatone Clinic 36. Itimpi Clinic 37. Kamitondo Clinic 38. Kawama Clinic 1 39. Kwacha Clinic 40. Mindolo 1 Clinic 41. Mulenga Clinic 42. Mwaiseni Clinic 43. Wusakile Government Clinic 44. ZAMTAN Clinic 1 45. Chavuma Clinic 1 46. Kamfinsa Prison Camp Clinic 47. Mwekera Clinic

ZPCT Quarterly Report (July 1 – September 30, 2008) 37 District Health Facility ART PMTCT CT Specimen Strengthe CC Lab Referral Strengthen Initiate Initiate Strengthen Initiate n for CD4 48. ZNS Clinic 1 49. Thompson District Hospital 3 50. Roan General Hospital Luanshya 51. Mikomfwa HC 52. Mpatamatu Sec 26 Urban Clinic 1 53. Kamuchanga District Hospital 3 54. Ronald Ross General Hospital 3 55. Clinic 3 Mine Clinic Mufulira 56. Kansunswa HC 57. Clinic 5 Clinic 58. Mokambo Clinic 59. Kalulushi Government Clinic 3 Kalulushi 60. Chambishi HC 1 61. Chibuluma Clinic Chililabomb 62. Kakoso District HC 3 we 63. Lubengele Urban Clinic 1 Lufwanyama 64. Mushingashi RHC 65. Lumpuma RHC 1 66. Shimukunami RHC 1 Totals 30 active 35 active 22 15 42 23 58 8 66 8 planned 23 planned ART – Antiretroviral Therapy; CC – Clinical Care; CT – Counseling and Testing; PMTCT – Prevention of Mother to Child Transmission

Services have started 1 = Outreach ART Site Services are planned, but not yet started 2 = Facility has a laboratory but not yet functional *New facilities are indicated in red. 3 = Referral laboratory for CD4

ZPCT Quarterly Report (July 1 – September 30, 2008) 38 Luapula Province: ZPCT-Supported Services

ART PMTCT CT Specimen District Health Facility CC Lab Referral Strengthen Initiate Strengthen Initiate Strengthen Initiate for CD4 1. Puta RHC Chienge 2. Kabole RHC 3. Hospital 3 4. Mbereshi Hospital 3 Kawambwa 5. Kawambwa HC 6. Mushota RHC 7. Mansa General Hospital 3 8. Senama HC 1 3 9. Central Clinic 10. Matanda RHC 11. Chembe RHC 12. Buntungwa RHC 13. Chipete RHC 14. Chisembe RHC 15. Chisunka RHC 16. Fimpulu RHC 17. Kabunda RHC 18. Kalaba RHC 19. Kalyongo RHC Mansa 20. Kasoma Lwela RHC 21. Katangwe RHC 22. Kunda Mfumu RHC 23. Luamfumu RHC 24. Mabumba RHC 25. Mano RHC 26. Mantumbusa RHC 27. Mibenge RHC 28. Moloshi RHC 29. Mutiti RHC 30. Muwang’uni RHC 31. Ndoba RHC 32. Nsonga RHC 33. Paul Mambilima RHC Milenge 34. Mulumbi Mwense 35. Mambilima HC (CHAZ) 1 36. Mwense HC 1 3 37. Chibondo RHC 38. Chipili RHC 39. Chisheta RHC 40. Kalundu RHC 41. Kaoma Makasa RHC 42. Kapamba RHC 43. Kashiba RHC 44. Katuta kampemba RHC 45. Kawama RHC 46. Lubunda RHC 47. Lukwesa RHC 48. Luminu RHC

ZPCT Quarterly Report (July 1 – September 30, 2008) 39 ART PMTCT CT Specimen District Health Facility CC Lab Referral Strengthen Initiate Strengthen Initiate Strengthen Initiate for CD4 49. Lupososhi RHC 50. Mubende RHC 51. Mukonshi RHC 52. Mununshi RHC 53. Mupeta RHC 54. Musangu RHC 2 55. Mutipula RHC 56. Mwenda RHC 57. Nchelenge RHC 58. Kashikishi RHC 59. Chabilikila RHC 60. Kabuta RHC 61. Kafutuma RHC Nchelenge 62. Kambwali RHC 63. Kanyembo RHC 64. Chisenga RHC 1 65. Kilwa RHC 1 66. St. Paul’s Hospital (CHAZ) 3 67. Lubwe Mission Hospital 3 Samfya (CHAZ) 68. Samfya Stage 2 Clinic 1 24 active 16 active 35 Totals 12 10 15 45 30 38 68 6 planned planned ART – Antiretroviral Therapy; CC – Clinical Care; CT – Counseling and Testing; PMTCT – Prevention of Mother to Child Transmission

Services have started 1 = Outreach ART Site Services are planned, but not yet started 2 = Facility has a laboratory but not yet functional *New facilities are indicated in red. 3 = Referral laboratory for CD4

ZPCT Quarterly Report (July 1 – September 30, 2008) 40

North Western Province: ZPCT-Supported Services

ART PMTCT CT Specime n District Health Facility CC Lab Strengthen Initiate Strengthen Initiate Strengthen Initiate Referral for CD4 1. Solwezi General Hospital 3 2. Solwezi UHC 3 3. Mapunga RHC Solwezi 4. St. Dorothy RHC 1 5. Mutanda HC 6. Meheba D RHC 7. Mumena RHC 8. Kabompo District Hospital 3 9. St. Kalemba RHC (CHAZ) 1 Kabompo 10. Mumbeji RHC 11. Kasamba RHC 12. Zambezi District Hospital 3 13. Zambezi UHC Zambezi 14. Mize HC 15. Chitokoloki Mission Hospital 3 (CHAZ) 16. Mwinilunga District Hospital 3 17. Kanyihampa HC Mwinilunga 18. Luwi Mission Hospital (CHAZ) 1 19. Ikelenge RHC 20. Lwawu RHC 21. Mufumbwe District Hospital 1 3 Mufumbwe 22. Matushi RHC Chavuma 23. Chiyeke RHC 1 2 1 2 Kasempa 24. Kasempa Urban Clinic 25. Nselauke RHC 10 active 7 active Totals 2 10 8 16 18 7 25 3 planned 11 planned ART – Antiretroviral Therapy; CC – Clinical Care; CT – Counseling and Testing; PMTCT – Prevention of Mother to Child Transmission

Services have started 1 = Outreach ART Site Services are planned, but not yet started 2 = Facility has a laboratory but not yet functional *New facilities are indicated in red. 3 = Referral laboratory for CD4

ZPCT Quarterly Report (July 1 – September 30, 2008) 41 Northern Province: ZPCT-Supported Services

District Health Facility ART PMTCT CT Specimen CC Lab Referral Strengthen Initiate Strengthen Initiate Strengthen Initiate for CD4 1. Kasama General Hospital 3 2. Kasama UHC 3. Location UHC 1 Kasama 4. Chilubula Mission RHC (CHAZ) 3 5. Lukupa RHC 2 6. Tazara UHC 7. Nakonde RHC 3 8. Chilolwa RHC Nakonde 9. Waitwika RHC 10. Mwenzo RHC 2 11. Mpika District Hospital 3 12. Mpika HC Mpika 13. Tazara Railway Clinic 14. Mpepo RHC 2 15. Hospital 3 Chinsali 16. Chinsali HC 17. Mbala General Hospital 3 18. Mbala UHC Mbala 19. Tulemane UHC 1 20. Senga Hills RHC 1 Mpulungu 21. Mpulungu HC 1 3 Isoka 22. Isoka District Hospital 23. Isoka UHC 3 Mporokoso 24. Hospital 25. Mporokoso UHC 1 Luwingu 26. Luwingu District Hospital 27. Namukolo Clinic Totals 12 active 14 active 9 5 11 16 16 11 27 6 planned 5 planned ART – Antiretroviral Therapy; CC – Clinical Care; CT – Counseling and Testing; PMTCT – Prevention of Mother to Child Transmission

Services have started 1 = Outreach ART Site Services are planned, but not yet started 2 = Facility has a laboratory but not yet functional *New facilities are indicated in red. 3 = Referral laboratory for CD4

ZPCT Quarterly Report (July 1 – September 30, 2008) 42 Attachment B: ZPCT Training Courses July 1 to September 30 2008

Table 1: Basic Counseling and Testing (CT) for HCWs Training Course Dates Province/District Number of Facilities Number Trained CT 14/09/08 to 28/09/08 Central Chibombo 1 5 Kabwe 1 8 Mkushi 1 3 Serenje 1 3 CT 21/07/08 to 03/08/08 Luapula Kawambwa 2 4 Mansa 5 5 Mwense 2 4 Nchelenge 3 5 Samfya 2 3 CT 31/08/08 to 14/09/08 Northern Chinsali 1 2 Isoka 4 11 Kasama 1 1 Mbala 2 3 Mpika 2 2 Mporokoso 1 2 Total 29 61

Table 2: Basic Counseling and Testing (CT) for Lay Counselors Training Dates Province/District Number of Number Course Facilities Trained CT for Lay 7/09/08 to Central Chibombo 4 4 Counselors 21/09/08 Kabwe 9 11 Serenje 2 2 CT for Lay 11/08/08 to Luapula Chienge 2 4 Counselors 22/08/08 Kawambwa 1 2 Mansa 7 7 Mwense 7 7 CT for Lay 31/08/08 to Copperbelt Chingola 2 2 Counselors 14/09/08 Kitwe 8 12 Mufulira 3 6 Total 45 57

Table 3: Basic Child Counseling for HCWs Training Dates Province/District Number of Number Course Facilities Trained Basic Child 08/09/08 to Luapula Chienge 1 2 Counseling 13/09/08 Kawambwa 1 5 Mwense 1 4 Samfya 1 4 Basic Child 21/08/08 to Copperbelt Chililabombwe 1 2 Counseling 28/08/08 Kalulushi 1 2 Kitwe 1 4 Luanshya 1 2 Mufulira 1 3 Total 9 28

ZPCT Quarterly Report (July 1 – September 30, 2008) 43

Table 4: Basic Child Counseling for Lay Counselors Training Dates Province/District Number of Number Course Facilities Trained Basic Child 14-19/07/08 Northern Kasama 3 4 Counseling Nakonde 1 1 Mpika 1 2 Mporokoso 1 2 Chinsali 1 2 Mbala 1 1 Mpulungu 1 1 Isoka 2 2 Basic Child 18/08/08 to North Kabompo 2 3 Counseling 23/08/08 Western Kasempa 1 3 Mufumbwe 1 2 Mwinilunga 2 2 Solwezi 1 4 Zambezi 1 1 Total 19 30

Table 5: Counseling Supervision for HCWs Training Dates Province/District Number of Number Course Facilities Trained Counseling 14/07/08 to Central Chibombo 2 4 Supervision 25/07/08 Kabwe 4 3 Mkushi 2 2 Serenje 1 1 Counseling 10/08/08 to Kabompo 2 3 Supervision 23/08/08 Northwestern Kasempa 1 1 Mufumbwe 1 2 Mwinilunga 1 1 Solwezi 2 2 Zambezi 1 1 Total 17 20

Table 6: CT Refresher for HCWs Training Dates Province/District Number of Number Trained Course Facilities CT Refresher 24/08/08 to Central Chibombo 1 4 for HCWs 30/08/08 Kabwe 1 11 Mkushi 1 2 Serenje 1 2 4 19

ZPCT Quarterly Report (July 1 – September 30, 2008) 44

Table 7: Prevention of Mother-to-Child Transmission (PMTCT) for HCWs Training Dates Province/District Number of Number Trained Course Facilities PMTCT for 24/08/08 to Copperbelt Chililabombwe 2 2 HCWs 31/08/08 Chingola 4 6 Kitwe 11 11 Mufulira 1 1 PMTCT for 27/07/08 to Northern Chinsali 1 2 HCWs 02/08/08 Isoka 4 9 Kasama 2 4 Mbala 3 5 Mpika 1 2 Mpulungu 1 1 Total 30 43

Table 8: Prevention of Mother-to-Child Transmission (PMTCT) for Lay Counselors Training Dates Province/District Number of Number Trained Course Facilities

PMTCT for Lay 24/08/08 to Central Chibombo 6 7 31/08/08 Kabwe 8 9 Mkushi 2 2 Serenje 2 2 Total 18 20

Table 9: PMTCT Refresher for HCWs Training Dates Province/District Number of Number Trained Course Facilities PMTCT 18/08/08 to Copperbelt Chiliabombwe 1 1 Refresher for 23/08/08 Chingola 3 5 HCWs Kalulushi 2 4 Kitwe 6 7 Mufulira 4 7 Ndola 1 1 PMTCT 4/08/08 to Copperbelt Luanshya 3 4 Refresher for 10/08/08 Ndola 13 17 HCWs Total 33 46

Table 10: Dry Blood Spot (DBS) Collection Training Dates Province/District Number Number Trained Course of Facilities DBS 16/07/08 Central Serenje 5 12 DBS 30/09/08 Copperbelt Chingola 6 17 DBS 24/09/08 Copperbelt Kitwe 15 17 DBS 26/09/08 Copperbelt Kalululshi/ Lufwanyama 2 16 DBS 25/09/08 Copperbelt Ndola 14 19 DBS 05/08/08 Luapula Mansa 24 25 DBS 10/09/08 Northwestern Kabompo 3 5 DBS 09/08/08 Northwestern Kasempa/Mufumbwe 4 5 ZPCT Quarterly Report (July 1 – September 30, 2008) 45 DBS 12/09/08 Northwestern Mwinilunga 2 6 DBS 29/09/08 Copperbelt Chililabombwe 2 13 DBS 17/07/08 Central Mkushi 6 12 DBS 11-14/08/08 Copperbelt Lufwanyama 3 9 DBS 09/09/08 Central Chibombo 7 7 DBS 2/07/08 Northern Isoka 1 7 Kasoka 1 3 DBS 26/08/08 Northern Nakonde 2 4 Total 97 174

Table 11: ART/OI In-House Training Dates Province/District Number of Number Trained Course Facilities ART/OI In- 25/09/08 to Copperbelt Chingola 1 19 House 25/09/08 ART/OI In- 28/07/08 to Copperbelt Kitwe 3 5 House 02/08/08 Ndola 1 27 ART/OI In- 17/08/08 to Copperbelt Kitwe 3 27 House 23/08/08 Total 8 78

Table 12: ART/OI Refresher for HCWs Training Dates Province/District Number of Number Trained Course Facilities ART/OI 05/08/08 to Central Chibombo 1 1 Refresher for 08/08/08 Kabwe 1 3 HCWs Mkushi 1 1 Serenje 1 1 ART/OI 04/08/08 to Copperbelt Chingola 1 4 Refresher for 10/08/08 Kalulushi 1 2 HCWs Kitwe 1 4 Luanshya 1 2 Mufulira 1 3 Ndola 1 2 ART/OI 05/08/08 to Luapula Mansa 1 3 Refresher for 08/08/08 Samfya 1 2 HCWs ART/OI 16/09/08 to Northwestern Chavuma 1 1 Refresher for 18/09/08 Kabompo 1 2 HCWs Mufumbwe 1 1 Solwezi 1 4 Zambezi 1 2 ART/OI 05/08/08 to Northern Chinsali 1 1 Refresher for 08/08/08 Kasama 1 2 HCWs Mpika 1 1 Nakonde 1 1 Total 21 43

Table 13: Pediatric ART/OIs Training Course Dates Province/District Number of Number Facilities Trained Pediatric ART 25/08/08 to Copperbelt Lufwanyama 2 4 /OIs 29/08/08 Ndola 1 19 Pediatric ART 28/07/08 to Luapula Chienge 1 1 /OIs 01/08/08 Kawambwa 1 1 Mansa 1 1 Mwense 4 5 Nchelenge 3 6 Samfya 2 5 ZPCT Quarterly Report (July 1 – September 30, 2008) 46 Pediatric ART 18/08/08 to Northwestern Chavuma 1 1 /OIs 22/08/08 Kabompo 1 2 Mufumbwe 1 2 Mwinilunga 1 2 Solwezi 2 6 Zambezi 1 2 Pediatric ART 24/08/08 to Northern Chinsali 1 1 /OIs 29/08/08 Isoka 1 1 Kasama 1 1 Mbala 1 2 Mpika 1 2 Mporokoso 1 1 Mpulungu 1 2 Nakonde 1 3 Pediatric ART 20/08/08 to Luapula Chienge 3 3 /OIs 26/08/08 Kawambwa 1 2 Mansa 3 7 Nchelenge 3 3 Samfya 1 1 Pediatric ART 22-27/09/08 Central Chibombo 1 1 /OIs 26/08/08 Kabwe 8 9 Mkushi 2 3 Serenje 2 2

Total 54 101

Table 14: Laboratory/Pharmacy Training Course Dates Province/District Number of Number Facilities Trained ART Comm. 08/09/08 to 12/09/08 Central Chibombo 5 6 ART Kabwe 9 11 Commodity Mkushi 3 3 Management B Serenje 4 4 for Lab ART Comm. 11-14/08/08 Northern Isoka 3 5 ART Kasama 3 5 Commodity Mbala 3 6 Management A Mporokoso 1 1 for Lab Mpulungu 1 2 ART Commodity 14-17/07/08 Copperbelt Ndola 9 13 Management A for Chingola 3 3 Lab Kitwe 2 2 Lufwanyama 3 3 Total 49 63

Table 15: Smart Care Software for M&E Staff and Data Entry Clerks Training Number of Dates Province/District Number Trained Course Facilities Smart Care 28/08/08 to 29/08/08 Luapula Nchelenge 10 18 Software Smart Care 27/08/08 to 27/08/08 Luapula Nchelenge 10 18 Forms Total 20 36

ZPCT Quarterly Report (July 1 – September 30, 2008) 47